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1) ECG stress test with exercise;

2) stress echocardiogram with exercise or using dobutamine or

a vasodilator;

3) exercise or vasodilator positron emission computed tomogra-

phy;

4) magnetic resonance imaging (MRI) of the heart with dobuta-

mine and vasodilator;

5) Hybrid imaging (single-photon emission computed tomogra-

phy) of the heart.

Non-invasive methods of assessing the anatomy of the coronary

arteries

Computed tomography of the coronary arteries is performed

without the introduction of contrast medium or after intravenous ad-

ministration of iodine-containing contrast.

Invasive coronary angiography

Invasive coronary angiography is performed to determine the fea-

sibility of revascularization.

3. What is the treatment tactics?

1. Identication and treatment of concomitant diseases that can

provoke or worsen the course of ischemic heart disease.

2. Lifestyle changes, correction of risk factors.

3. To give up smoking.

4. Blood pressure control. The goal is to lower blood pressure

<140/90 mm Hg. Art. or BP <140/85 mm Hg. Art. with Chronic kid-

ney disease or diabetes mellitus, in patients> 80 years old <150/80

mm Hg. Art.

If a patient with coronary artery disease has dyslipidemia, this

signicantly increases the risk of death, and in such cases, correction

of the blood lipid spectrum should be carried out more vigorously than

in people without signs of coronary artery disease, achieving a de-

crease in total cholesterol levels below 5.2 mmol / L, LDL <1.8 mmol

/ L, triglycerides <1.7 mmol / L.

Stopping an attack of stable angina pectoris:

1) stop physical activity;

2) take a sitting position with lowered legs;

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3) take 1 nitroglycerin tablet sublingually (500 mcg) or 1-2 doses

(1.25-2.5 mg) of isosorbide dinitrate aerosol;

4) if ineective, repeat nitroglycerin intake every 5 minutes until

a maximum dose of 1.2 mg is reached for 15 minutes. If there is no

eect from 3 tablets, it is necessary to arrange a call to a doctor or an

ambulance team.

Medication. Three classes of drugs are used: nitrates, β-blockers,

and calcium antagonists. The goal of antianginal therapy is to reduce

myocardial oxygen demand and / or increase myocardial perfusion.

Low-dose aspirin is recommended for all patients with stable coronary

artery disease. Clopidagrel is recommended as an alternative drug in

cases of aspirin intolerance. Statins are recommended for all patients

with stable coronary artery disease. Angiotensin-converting enzyme

inhibitors or angiotensin II receptor blockers are indicated in the pres-

ence of heart failure, arterial hypertension and diabetes mellitus.

Other anti-ischemic drugs (Ivabradine. The initial dose is 5 mg

2 times a day. Nicorandil. It is used in a dose of 20 mg 2 times a day

Trimetazidine It is used in a dose of 35 mg 2 times a day Ranolosin

Starts 500 mg 2 times a day Allopurinol It is used in tablets 600 mg

a day Molsidomin It is used 8 mg 2 times a day { {1}} Lipid-lowering

therapy

All patients, in the absence of contraindications, should be pre-

scribed statins.

If the target level of LDL cholesterol is not achieved, combination

therapy of a statin with ezetimibe is necessary. LDL apheresis or new

lipid-lowering drugs (PCSK9 inhibitors).

4. Medical and labor expertise. Dispensary observation.

Temporary disability. Angina pectoris: rst-onset 10–12

days; stress II FC - 10-15 days; III FC - 20-30 days; IV FC - up to

3–3.5 months; unstable angina pectoris - 25-30 days, acute coronary

insuciency - 40-50 days. MI - small focal without complications 60–

80 days, with complications 3–3.5 months, large focal - 4–5 months.

СН I Art. - 14-21 days, II Art. - 28-42 days, III Art. - 90-120 days.

Heart rhythm disturbances - high-grade ventricular extrasystoles for

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7-10 days; complete atrioventricular block with an attack of Morgag-

ni - Adams - Stokes 14–20 days; incomplete atrioventricular block II

stage. 7-10 days; paroxysmal supraventricular tachycardia 5-10 days;

paroxysm of atrial brillation (utter) of the atria 7-10 days; implanta-

tion of pacemaker - 2 months.

Contraindicated types and working conditions. Work associated

with constant or episodic signicant physical (the energy intensity of

the pile is more than 4-5 kcal / min) and neuropsychic stress; stay at

altitude; exposure to vascular and neurotropic poisons; in unfavorable

microclimatic and extreme conditions. Absolutely contraindicated for

patients with pacemaker is work associated with a forced position of

the body, the prescribed pace; exposure to strong static charges, mag-

netic and microwave elds, exposure to electrolytes, strong induction

of thermal and light radiation from stoves and radiators: pronounced

general and local vibration, as well as potential danger to others and

the for the occurred violations of the EKS.

Permanent disability. Indications for referral to the MSEC bu-

reau: Angina pectoris III and IV FC; severe dysfunctions of the car-

diovascular system after MI; severe and moderate heart rhythm dis-

turbances, taking into account the underlying disease that caused their

occurrence, the patient’s absolute dependence on the pacemaker; SN

II, III Art., The presence of contraindications in the nature and condi-

tions of work.

III group of disability is established in connection with the limi-

tation of the ability to self-service, movement, work activity I Art.

in the following cases: exertional angina II (less often - III) FC, CH

I or II A st. (II FC according to NYHA); transferred small or large-

focal myocardial infarction without severe complications in the acute

and subacute stages, or the development in the acute period of tran-

sient atrioventricular blockade, extrasystole not higher than grade 3,

HF I st. by Killip, natural ECG dynamics; completion of an eective

phased rehabilitation program; moderate deviations in ECG monitor-

ing in conditions of everyday activity, mild NDS; moderate decrease

in exercise tolerance (75 W / min) and coronary reserve according to

VEM; a moderate increase in the size of the heart cavities in systole

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and diastole according to echocardiography, moderate disorders of the

general (EF 45%) and regional (papillary muscle dysfunction, limited

zones of LV myocardial hypokinesia).After the pacemaker implanta-

tion and the stable course of the underlying disease, the patients are

recognized as invalids of the III group in the case of HF II – III ac-

cording to NYHA, cardiophobic reaction, angina pectoris II FC, the

development of a pacemaker syndrome with moderate dysfunctions

of the cardiovascular and central nervous system. Patients have a need

to limit the amount of work in their previous profession or a loss of

professional suitability due to the eect on the body of pronounced

physical stress, unfavorable microclimatic conditions while maintain-

ing the ability to learn to acquire an uncontradicted profession.

II group of disability is established in connection with the limita-

tion of the ability to self-service, movement, work II Art. in the fol-

lowing cases: angina pectoris III FC, postponed large-focal (transmu-

ral) MI with severe complications in the acute and subacute stages

(paroxysmal tachycardia, atrioventricular block II stage - III stage,

extrasystole of high gradations, heart failure II – III class according

to Killip, acute aneurysm of the heart, pericarditis, etc.), delayed ECG

dynamics, signicantly pronounced deviations in monitoring the ECG

in conditions of daily everyday activity; NDS of medium degree;

marked decrease in exercise tolerance (50 W / min) and coronary re-

serve, according to VEM; a signicant increase in heart cavities in

systole and diastole by echocardiography, a pronounced violation of

the total (EF 35%) and regional (dysfunction of papillary.

Clinical case No. 2

1. Formulate a preliminary diagnosis. Coronary heart disease:

acute Q-myocardial infarction in the region of the lower wall. The

diagnosis was made on the basis of complaints of pain in the epigas-

tric region, accompanied by weakness, sweating, nausea; anamnesis

data: after taking Nitroglycerin under the tongue, the pain decreased;

the data of clinical and laboratory research: on the taken ECG, a deep

Q wave was revealed in the III and aVF leads; the ST segment in the

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same leads is raised above the isoline, arcuate, turns into a negative

T wave.

2. Assign additional research methods.

Basic examination in patients with coronary artery disease in-

cludes standard biochemical tests: troponin T or I, complete blood

count with hemoglobin and leukocyte counts, glycated hemoglobin

and fasting plasma glucose, serum creatinine levels, and assessment

of renal function by creatinine clearance , blood lipid spectrum, as-

sessment of thyroid function, hepatic function tests, creatinine phos-

phokinase level, brain natriuretic peptide type B (BNP) or GC-B level,

peptide hormone and its precursor (BNP / NT-proBNP).

Instrumental studies

Electrocardiogram (ECG) at rest and / or during or immediately

after an attack of chest pain, outpatient ECG monitoring (in patients

with suspected arrhythmia and vasospastic angina), echocardiography

at rest to identify violations of regional contractility, determination

of ejection fractions and assessment of diastolic function of the left

ventricle, ultrasound examination of sleep arteries to determine the

thickness of the intima media and / or the detection of atherosclerotic

plaques, chest x-ray.

Studies according to indications

Non-invasive methods for the diagnosis of ischemia:

1) ECG stress test with exercise;

2) stress echocardiogram with exercise or using dobutamine or

a vasodilator;

3) Exercise or vasodilator positron emission computed tomogra-

phy;

4) magnetic resonance imaging (MRI) of the heart with dobuta-

mine and vasodilator;

5) Hybrid imaging (single-photon emission computed tomogra-

phy) of the heart.

Non-invasive methods for assessing the anatomy of the coronary

arteries

t.me/medicina_free

Computed tomography of the coronary arteries is performed

without the introduction of a contrast agent or after intravenous ad-

ministration of iodine-containing contrast.

Invasive coronary angiography

Invasive coronary angiography is performed to determine if.

3. What is the treatment tactics?

There are mainly three classes of drugs used: nitrates, β-blockers