Coronary heart disease: treatment

First of all, it is necessary to explain to the patient the nature of his disease, the impact of basic treatment measures, and especially the importance of lifestyle changes.

It is advisable to make a clear plan of action: quit smoking, lose weight and start physical training.

Along with normalizing the lifestyle, treatment of associated risk factors and elimination of diseases that increase the myocardium's need for oxygen are carried out: arterial hypertension, anemia, hyperthyroidism, infectious diseases, etc. It has been shown that a decrease in cholesterol levels to 4.5-5 mmol/l or by 30% of the initial level is accompanied by a decrease in the degree of stenosis (due to a decrease in the size of atherosclerotic plaques), a decrease in the frequency of angina pectoris and myocardial infarction, and a decrease in mortality in patients with coronary heart disease.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Drug treatment of coronary heart disease

The main antianginal drugs include nitrates, beta-blockers and calcium antagonists.

Nitrates. The effectiveness of nitrates in stopping angina attacks and in prophylactic administration before exercise is well known. However, with constant administration of nitrates, for example, daily 3-4 times a day, tolerance to nitrates occurs with a decrease or disappearance of the anti-ischemic effect. To prevent the development of tolerance, it is advisable to take a break of at least 10-12 hours during the day, i.e. prescribe nitrates either mainly during the daytime, or only at night (depending on the specific situation), and use drugs from other groups for constant administration.

It should be remembered that the use of nitrates does not improve the prognosis, but only eliminates angina, i.e. it is symptomatic.

Beta blockers. Beta blockers are the drug of choice for the treatment of angina. In addition to the antianginal effect, a sign of sufficient beta blockade is a decrease in heart rate to less than 60 per minute and the absence of pronounced tachycardia during exercise. In the case of initial pronounced bradycardia, for example, with a heart rate of less than 50 per minute, beta blockers with internal sympathomimetic activity (beta blockers with ICA) are used, for example, pindolol (visken).

Calcium antagonists. Calcium antagonists are the drug of choice for spontaneous ("vasospastic") angina. For angina of effort, calcium antagonists such as verapamil and diltiazem are almost as effective as beta-blockers. It should be recalled that the use of short-acting forms of nifedipine is currently not recommended. Preference should be given to verapamil, diltiazem and prolonged forms of dihydropyridine calcium antagonists (amlodipine, felodipine).

The use of other drugs is justified in case of refractoriness to "standard" therapy, the presence of contraindications to the use of a particular group of antianginal drugs or their intolerance. For example, if there are contraindications to beta-blockers and verapamil, you can try using cordarone.

There are reports of the antianginal effect of euphyllin: taking euphyllin reduces the manifestation of ischemia during a stress test. The mechanism of the antianginal action of euphyllin is explained by the so-called "Robin Hood effect" - a decrease in vasodilation of unaffected coronary arteries (antagonism with adenosine) and redistribution of blood flow in favor of ischemic areas of the myocardium (a phenomenon opposite to the "steal phenomenon"). In recent years, data have appeared that adding cytoprotective drugs mildronate or trimetazidine to antianginal therapy can enhance the anti-ischemic effect of antianginal drugs. Moreover, these drugs have their own anti-ischemic effect.

In order to prevent myocardial infarction and sudden death, all patients are prescribed aspirin 75-100 mg/day, and in case of intolerance or contraindications - clopidogrel. Many specialists believe that the prescription of statins is also indicated for all patients with coronary heart disease, even with normal cholesterol levels.

Antianginal drugs

Preparation	Average daily doses (mg)	Frequency of reception
Nitrates
Nitroglycerine	As needed
Nitrosorbide	40-160	2-3
Trinitrolong	6-10	2-3
Ointment with niroglycerin	1-4 cm	1-2
Isoket (cardiquet)-120	120 mg	1
Isoket (cardiquet) retard	40-60 mg	1-2
Isosorbide-5-mononirate (monocinque, efox)	20-50	1-2
Nitroderm patch	25-50	1
Molsidomine (Corvaton, Dilasidom)	8-16	1-2
Beta blockers
Propranolol (obzidan)	120-240	3-4
Metoprolol (Metocard, Corvitol)	100-200	2-3
Oxprenolol (Trazicor)	120-240	3-4
Pindolol (whisken)	15-30	3-4
Nadolol (korgard)	80-160 mg	1
Atenolol (Tenormin)	100-200 mg	1
Bisoprolol (concor)	5-10 mg	1
Carvedilol (Dilatrend)	50-100 mg	1-2
Nebivolol (Nebilet)	5 mg	1
Calcium antagonists
Verapamil (Isoptin SR)	240 mg	1
Nifedipine GITS (osmo-adalat)	40-60 mg	1
Diltiazem (dilren)	300 mg	1
Diltiazem (altiazem RR)	180-360 mg	1-2
Isradipine (lomir SRO)	5-10 mg	1
Amlodipine (Norvasc)	5-10 mg	1
Additional drugs
Cordarone	200 mg	1
Euphyllin	450 mg	3
Mildronate (?)	750 mg	3
Trimetazidine (?)	60 mg	3

Features of treatment of various types of angina

Angina pectoris

For relatively inactive patients with moderate angina, especially in the elderly, it is often sufficient to recommend taking nitroglycerin in cases where the attack does not pass on its own after cessation of exertion within 2-3 minutes and/or prophylactic administration of isosorbide dinitrate before exertion, for example, nitrosorbide 10 mg (sublingually or orally) or isosorbide-5-mononitrate 20-40 mg orally.

In case of more severe angina, beta-blockers are added to the treatment. The dose of beta-blockers is selected not only based on the antianginal effect, but also on the effect on the heart rate. The heart rate should be about 50 beats per minute.

If there are contraindications for beta-blockers or if treatment with beta-blockers is insufficiently effective, calcium antagonists or prolonged-release nitrates are used. In addition, amiodarone can be used instead of beta-blockers. In angina of III-IV FC, combinations of 2-3 drugs are often used, for example, constant intake of beta-blockers and calcium antagonists and prophylactic intake of prolonged nitrates before exercise.

One of the most common mistakes when prescribing antianginal drugs is their use in insufficient doses. Before replacing or adding a drug, it is necessary to evaluate the effect of each drug in the maximum tolerated dose. Another mistake is the appointment of constant intake of nitrates. It is advisable to prescribe nitrates only before the planned load that causes angina. Constant intake of nitrates is useless or even harmful, because it causes rapid development of tolerance - a progressive decrease or complete disappearance of the antianginal effect. The effectiveness of drugs is constantly monitored by increasing tolerance to physical activity.

In patients with persistent severe angina (FC III-IV), despite drug treatment, coronary angiography is indicated to clarify the nature and extent of damage to the coronary arteries and to assess the possibility of surgical treatment - balloon coronary angioplasty or aortocoronary bypass grafting.

Features of treatment of patients with syndrome X. Syndrome X is called angina pectoris in patients with normal coronary arteries (diagnosis is established after coronary angiography). The cause of syndrome X is a decrease in the ability of small coronary arteries to vasodilate - "microvascular angina".

Surgical treatment is impossible in patients with syndrome X. Drug therapy for syndrome X is also less effective than in patients with coronary artery stenosis. Refractory to nitrates is often observed. Antianginal effect is observed in about half of the patients. Drug therapy is selected by trial and error, primarily assessing the effectiveness of nitrates and calcium antagonists. In patients with a tendency to tachycardia, treatment begins with beta-blockers, and in patients with bradycardia, a positive effect may be observed from prescribing euphyllin. In addition to antianginal drugs, alpha-1 blockers, such as doxazosin, may be effective in syndrome X. Additionally, such drugs as mildronate or trimetazidine are used. Considering that patients with syndrome X have a very good prognosis, the basis of treatment is rational psychotherapy - an explanation of the safety of this disease. The addition of imipramine (50 mg / day) to antianginal drugs increases the effectiveness of treatment.

Spontaneous angina

To stop attacks of spontaneous angina, sublingual nitroglycerin is used first. If there is no effect, nifedipine is used (the tablet is chewed).

Calcium antagonists are the drug of choice for preventing recurrent attacks of spontaneous angina. Calcium antagonists are effective in approximately 90% of patients. However, it is often necessary to use maximum doses of calcium antagonists or a combination of several drugs of this group at the same time, up to the use of all three subgroups at the same time: verapamil + diltiazem + nifedipine. If the effect is insufficient, prolonged nitrates are added to the treatment. Within a few months, most patients experience a noticeable improvement or complete remission. Especially often, rapid disappearance of the tendency to spastic reactions and long-term remission are observed in patients with isolated spontaneous angina, without concomitant angina of effort (in patients with normal or slightly changed coronary arteries).

Beta blockers may increase the tendency to vasospastic reactions of the coronary arteries. However, if attacks of spontaneous angina occur in a patient with severe angina, calcium antagonists are used in combination with beta blockers. The most appropriate is the use of nibivolol. There are reports of fairly high efficiency of cordarone. In some patients, the administration of doxazosin, clonidine or nicorandil is effective.

Nocturnal angina

There are 3 possible variants: minimal-effort angina (angina that occurs in the supine position - "decubitus angina" and angina in dreams with an increase in heart rate and blood pressure), angina due to circulatory failure and spontaneous angina. In the first two cases, angina is the equivalent of paroxysmal nocturnal dyspnea. In all 3 variants, it may be effective to prescribe prolonged-release nitrates at night (prolonged forms of isosorbide dinitrate and mononitrate, nitroderm patch, nitroglycerin ointment). In case of a presumptive diagnosis of minor-effort angina, it is advisable to evaluate the effect of beta-blockers. In spontaneous angina, calcium antagonists are most effective. In case of circulatory failure, nitrates and ACE inhibitors are prescribed. By consistently evaluating the effectiveness of prescribing various drugs and their combinations, the most acceptable treatment option is selected.

[ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ], [ 19 ], [ 20 ]

Surgical methods of treatment of coronary heart disease

The main indication for surgical treatment of coronary heart disease is the persistence of severe angina (FC III-IV), despite intensive drug treatment (refractory angina). The very presence of angina of FC III-IV means that drug therapy is not effective enough. Indications and the nature of surgical treatment are specified based on the results of coronary angiography, depending on the degree, prevalence and characteristics of the coronary artery lesion.

There are 2 main methods of surgical treatment of coronary heart disease: balloon coronary angioplasty (BCA) and coronary artery bypass grafting (CABG).

Absolute indications for CABG are the presence of left main coronary artery stenosis or three-vessel disease, especially if the ejection fraction is reduced. In addition to these two indications, CABG is advisable in patients with two-vessel disease if there is proximal stenosis of the left anterior descending branch. CABG in patients with left main coronary artery stenosis increases the life expectancy of patients compared to drug treatment (5-year survival after CABG is 90%, with drug treatment - 60%). CABG is somewhat less effective in three-vessel disease combined with left ventricular dysfunction.

Coronary angioplasty is a method of so-called invasive (or interventional) cardiology. When performing coronary angioplasty, stents are usually inserted into the coronary arteries - metal or plastic endovascular prostheses. The use of stents has been shown to reduce the incidence of reocclusions and restenoses of the coronary arteries by 20-30%. If there is no restenosis within 1 year after CAP, the prognosis for the next 3-4 years is very good.

The long-term results of CAP have not yet been sufficiently studied. In any case, the symptomatic effect - the disappearance of angina - is noted in most patients.