Ischemic heart disease: treatment

First of all, it is necessary to explain to the patient the essence of his illness, the influence of the main medical measures, especially the importance of changing the way of life.

It is desirable to draw up a clear plan of activities: quit smoking, lose weight and start physical training.

Simultaneously with the normalization of the lifestyle, treatment of concomitant risk factors and the elimination of diseases that increase the need for myocardium in oxygen are conducted: arterial hypertension, anemia, hyperthyroidism, infectious diseases, etc. It was shown that a decrease in cholesterol level to 4.5-5 mmol / l or 30% of the initial one is accompanied by a decrease in the degree of stenosis (due to a decrease in the amount of atherosclerotic plaques), a decrease in the frequency of angina and myocardial infarction, and a decrease in the mortality of patients with IHD.

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

Medical treatment of ischemic heart disease

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

Nitrates. The effectiveness of nitrates is well known in the management of angina attacks and in the prevention of pre-exercise. However, with a constant intake of nitrates, for example, daily 3-4 times a day, there is tolerance to nitrates with a decrease or disappearance of anti-ischemic action. To prevent the development of tolerance, it is advisable to take a break not less than 10-12 hours during the day, i.e. Prescribe nitrates, either predominantly in the daytime, or only overnight (depending on the specific situation), and for regular use use drugs from other groups.

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

Beta-blockers. Beta-blockers are a means of choice in the treatment of angina pectoris. In addition to the antianginal effect, a sign of sufficient beta blockade is a decrease in heart rate of less than 60 min and no significant tachycardia with exercise. At the initial expressed bradycardia, for example, at a heart rate of less than 50 per min, beta-blockers with intrinsic sympathomimetic activity (beta-blockers with BCA), for example, pindolol (vecin) are used.

Calcium antagonists. Calcium antagonists are a means of choice for spontaneous ("vasospastic") angina pectoris. With angina pectoris, 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 appointment of other drugs is justified with refractory to "standard" therapy, the presence of contraindications to the appointment of a 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 an antianginal effect of euphyllin: the use of euphyllin reduces the manifestation of ischemia in a sample with a load. The mechanism of the antianginal action of euphyllin is explained by the so-called. "The Robin Hood effect" - reduced 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 "stealing phenomenon"). In recent years, there have been reports that the addition of anti-anginal drugs to the preparations of the cytoprotective action of mildronate or trimetasidium may enhance the antiischemic effect of antianginal drugs. Moreover, these drugs have their own anti-ischemic action.

In order to prevent the occurrence of myocardial infarction and sudden death, all patients are prescribed aspirin 75-100 mg / day, and if it is intolerant or if there are contraindications - clopidogrel. Many experts believe that the appointment of statins is also indicated to all patients with IHD, even with a normal level of cholesterol.

Antianginal drugs

A drug	Average daily doses (mg)	Frequency of reception
Nitrates
Nitroglycerine	According to need
Nitrosorbide	40-160	2-3
Trinitrolong	6-10	2-3
Ointment with niroglycerin	1-4 centimeters	1-2
Isoket (card-card) -120	120 mg	1
Isoket (kardiket) retard	40-60 mg	1-2
Isosorbide-5-mononitrate (monochinke, efoks)	20-50	1-2
Nitroderm plaster	25-50	1
Molsidomine (Corvatone, dilacid)	8-16	1-2
Beta-blockers
Propranolol (Obsidan)	120-240	3-4
Metoprolol (metokard, corvitol)	100-200	2-3
Oxprenolol (tracicore)	120-240	3-4
Pindolol (vine)	15-30	3-4
Nadolol (Cowgard)	80-160 mg	1
Atenolol (tenormin)	100-200 mg	1
Bisoprolol (Concor)	5-10 mg	1
Carvedilol (dilarend)	50-100 mg	1-2
Nebivolol (non-ticket)	5 mg	1
Calcium antagonists
Verapamil (isoptin SR)	240 mg	1
Nifedipine GITS (osmo-adalate)	40-60 mg	1
Diltiazem (dilrin)	300 mg	1
Diltiazem (althiazem PP)	180-360 mg	1-2
Isradipine (Lomir SRO)	5-10 mg	1
Amlodipine (norvasc)	5-10 mg	1
Additional drugs
Kordaron	200 mg	1
Eufillin	450 mg	3
Mildronate (?)	750 mg	3
Trimetazidine (?)	60 mg	3

Features of treatment of various variants of angina pectoris

Angina of Stress

Relatively inactive patients with moderate angina, especially in old age, it is often enough to recommend the intake of nitroglycerin in cases when the attack does not pass independently after the termination of the load for 2-3 min and / or prophylactic intake of isosorbide dinitrate before the load, for example, nitrosorbide 10 mg (under the tongue or inside) or isosorbide-5-mononitrate 20-40 mg orally.

With more severe exertional angina, beta-blockers are added to the treatment. The dose of beta-blockers is selected not only for the antianginal effect, but also for the effect on the heart rate. The heart rate should be about 50 per min.

In the presence of contraindications for beta-blockers, or with insufficient effectiveness of treatment with beta-blockers, calcium antagonists or nitrates of prolonged action are used. In addition, amiodarone can be used instead of beta-blockers. With stenocardia III-IV FC, combinations of 2-3 drugs are often used, for example, the constant intake of beta-blockers and calcium antagonists and the prophylactic reception of prolonged nitrates before the load.

One of the most common mistakes in prescribing antianginal drugs is their use in insufficient doses. Before replacing or adding the drug, it is necessary to evaluate the effect of each drug in the maximum tolerated dose. Another mistake is the appointment of a permanent intake of nitrates. Nitrates should be prescribed only before the planned load, which causes angina pectoris. The constant intake of nitrates is useless or even harmful, because causes rapid development of tolerance - progressive reduction or complete disappearance of antianginal action. The effectiveness of drugs is constantly monitored to increase the tolerance of physical activity.

Patients with persisting severe angina pectoris (FCIII-IV), despite medical treatment, are shown to perform coronary angiography to clarify the nature and extent of coronary artery disease and to assess the possibility of surgical treatment - balloon coronaroangioplasty or coronary artery bypass grafting.

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

In patients with X syndrome, surgical treatment is not possible. Pharmacotherapy for X syndrome is also less effective than in patients with coronary artery stenoses. Refractory to nitrates is often noted. An antianginal effect is observed in about half of the patients. Drug treatment is selected by trial and error, first of all, the effectiveness of nitrates and calcium antagonists. In patients with a tendency to tachycardia, treatment is started with beta-blockers, and in patients with bradycardia, a positive effect can be observed from the appointment of eufillin. In addition to antianginal drugs with X syndrome, a-1-blockers, for example doxazosin, can be effective. Additionally, drugs such as mildronate or trimetazidine are used. Given that a very good prognosis in patients with X syndrome, the rationale for therapeutic interventions is rational psychotherapy-an explanation of the safety of this disease. Addition of imipramine to antianginal drugs (50 mg / day) increases the effectiveness of treatment.

Spontaneous angina

For relief of attacks of spontaneous angina, sublingual administration of nitroglycerin is primarily used. If there is no effect, nifedipine is used (the tablet is chewed).

To prevent the occurrence of repeated attacks of spontaneous angina, the choice is made by calcium antagonists. Calcium antagonists are effective in about 90% of patients. However, it is often necessary to use maximal doses of calcium antagonists or a combination of several drugs of this group simultaneously, up to the use of all three subgroups simultaneously: verapamil + diltiazem + nifedipine. If the effect is insufficient, prolonged nitrates are added to the treatment. Within a few months, most patients experience marked improvement or complete remission. Especially often the rapid disappearance of inclinations to spastic reactions and prolonged remission is observed in patients with isolated spontaneous angina, without concomitant angina of exertion (in patients with normal or moderately coronary arteries).

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

Night angina

There are 3 options: stenocardia of minimal stress (stenocardia arising in the supine position - "angina decubitus" and angina in dreams with increased heart rate and blood pressure), stenocardia due to circulatory insufficiency and spontaneous angina. In the first two cases, angina is equivalent to paroxysmal nocturnal dyspnea. In all 3 variants, the administration of nitrates of prolonged action at night (prolonged forms of isosorbide dinitrate and mononitrate, nitrodermal patch, nitroglycerin ointment) can be effective. At the presumptive diagnosis of stenocardia of small strains - it is advisable to evaluate the effect of beta-blockers. With spontaneous angina, calcium antagonists are most effective. With circulatory failure, nitrates and ACE inhibitors are prescribed. Consistently evaluating the effectiveness of the appointment of various drugs and their combinations, select the most appropriate treatment option.

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

Surgical methods of IHD treatment

The main indication for the surgical treatment of IHD is the preservation of severe angina pectoris (FC III-IV), despite intensive medication (refractory angina). The very presence of angina III-IV FC means that pharmacotherapy is not effective enough. The indications and nature of surgical treatment are refined based on the results of coronary angiography, depending on the degree, prevalence and characteristics of the lesion of the coronary arteries.

There are 2 main ways of surgical treatment of IHD: balloon coronaroangioplasty (CAP) and coronary artery bypass graft (CABG).

Absolute indications for CABG are stenosis of the left coronary artery trunk or three-vessel lesion, especially if the ejection fraction is reduced. In addition to these two indications, CABG is useful in patients with a two-vessel lesion, if there is a proximal stenosis of the left anterior descending branch. Carrying out CABG in patients with stenosis of the left coronary artery trunk increases the life expectancy of patients in comparison with drug treatment (survival for 5 years after CABG is 90%, in case of medical treatment - 60%). It is somewhat less effective to perform CABG in three-vessel lesions in combination with left ventricular dysfunction.

Coronaroangioplasty is a method of so-called. Invasive (or interventional) cardiology. When carrying out coronaroangioplasty, as a rule, stents are inserted into the coronary arteries - metal or plastic endovascular prostheses. Against the background of the use of stents, there was a decrease in the incidence of reocclusions and restenoses of the coronary arteries by 20-30%. If there is no restenosis after CAP for 1 year - a forecast for the next 3-4 years is very good.

The long-term results of the KAP are not sufficiently studied. In any case, the symptomatic effect - the disappearance of angina pectoris - is noted in most patients.