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MODERN SOLUTIONS TO THE ORIGIN AND PREVENTION OF STABLE ANGINA
PECTORIS
Axmedov Abbos
Jòraboyev Ozodbek
Ergashev Davlat
Mamatov Yusufjon
Samarkand State Medical University, Department of Therapy, Cardiology and Functional
Diagnostics, 1st year ordinators.
https://doi.org/10.5281/zenodo.11523308
Abstract
. For many years, coronary heart disease (CHD) has been the main cause of death
in many economically developed countries, including Uzbekistan. New diagnostic technologies
and improvements in the prognostic assessment of patients, along with the ever-evolving evidence
base for different treatment strategies, require regular review and updating of existing
recommendations.
Key words
: Angina, tension angina, stable angina.
СОВРЕМЕННЫЕ ПУТИ ВОЗНИКНОВЕНИЯ И ПРОФИЛАКТИКИ
СТАБИЛЬНОЙ СТЕНОКАРДИИ.
Аннотация.
На протяжении многих лет ишемическая болезнь сердца (ИБС)
является основной причиной смертности во многих экономически развитых странах, в
том числе в Узбекистане. Новые диагностические технологии и улучшения в
прогностической оценке пациентов, а также постоянно развивающаяся доказательная
база для различных стратегий лечения требуют регулярного пересмотра и обновления
существующих рекомендаций.
Ключевые слова:
Стенокардия, стенокардия напряжения, стабильная стенокардия.
Complications
: The most commonly diagnosed form of coronary artery disease is stable
angina. Stable angina is a clinical syndrome characterized by chest discomfort that occurs during
physical exertion or emotional stress. The attack occurs at the same load level and passes within
1-5 minutes. after termination.
Purpose of study:
Patients with stable angina are considered to have a relatively good
prognosis. In clinical trials of antianginal and prophylactic therapy and/or revascularization, the
annual mortality rate is 1.2-2.4% per year [1-6], the annual rate of cardiac death is 0.6-1.4% and
death between non-lim myocardial infarction (MI). 0.6% in the RITA-2 (Second Randomized
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Interventional Treatment of Angina) trial [4] and 2.7% in the COURAGE (Clinical Outcomes
Using Revascularization and Aggressive Drug Evaluation) [1] trial.
However, the individual prognosis of a particular patient with stable angina can vary
significantly depending on his main clinical, functional and anatomical features.
Research results:
This is shown in data from the REACH (Reducing Atherothrombosis
for Sustainable Health) [7] registry: the annual mortality rate in high-risk patients with peripheral
arterial disease, post-infarction cardiosclerosis and diabetes mellitus (DM) is 3.8% formed, and in
low-risk patients it was 3.8%.
Prognostic assessment is an important part of the diagnosis of stable angina. On the one
hand, there is a need to identify patients with more severe disease whose outcomes may be
improved by more aggressive treatment, including revascularization. On the other hand, it is also
important to identify patients with less severe disease and better prognosis, thereby avoiding
unnecessary aggressive tests and revascularization procedures.
The prognosis is determined by several factors:
1. Coronary reserve, i.e. increased work of the left ventricle and the possibility of sufficient
increase in coronary blood flow with the amount of myocardium with insufficient blood supply.
In conditions of energy starvation, the contractility of the myocardium can be significantly reduced,
which leads to ischemia of a large part of the left ventricle or a small heart failure, but this is
enough to reduce the function of the pump and increase the existing contractility disorders.
previous myocardial injury.
2. risk factors that accelerate the development of atherosclerosis and the formation of
unstable plaque, the sudden rupture of atheromatous plaque responsible for the development of
unstable angina and acute coronary events are not related to the severity of pre-existing stenosis.
According to the 2013 ESC guidelines for the diagnosis and treatment of stable angina,
once stable CAD is diagnosed and optimal medical therapy (OMT) is initiated, coronary risk
stratification is performed based on invasive tests that are not usually available. selection of
patients who may benefit from revascularization. Depending on the severity of symptoms, early
coronary angiography can be performed with appropriate confirmation of the importance of
stenoses and subsequent revascularization, bypassing noninvasive tests. Revascularization confers
a clear prognostic benefit only in high-risk patients and provides little or no improvement in
prognosis in those who already have a good prognosis.
Previously, in the ESC recommendations [8], an annual risk of cardiac death greater than
2% was considered the recommended threshold for revascularization. The 2013 guidelines [9]
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revised the severity of angina pectoris, suggesting that surgical treatment significantly improves
the prognosis compared to medical treatment and that high-risk patients should be considered those
with a risk of cardiac death greater than 3% per year did
Summary
: Duke treadmill index = exercise time in minutes - 5 × ST deviation in mm - 4
× angina index (angina index: 0 - angina was absent, 1 - angina appeared, 2 - angina to stop the
test caused).
An approximate assessment of the risk of myocardial infarction and death using the Duke
treadmill index (Table 2) helps to choose the next tactics of patient management:
For low-risk patients, further stress imaging and coronary angiography are considered
inappropriate, and drug therapy is recommended;
For moderate-risk patients, stress imaging is recommended (Table 2), myocardial perfusion
with normal or normal heart size during exercise is a favorable prognostic marker, and drug
treatment is recommended for them. will be done. in patients and in the presence of left ventricular
dysfunction - revascularization [10, 11].
The recommendations of the EOC suggest some changes in the tactics of drug treatment of
stable angina:
It is recommended to start prevention of attacks by prescribing β-blockers and/or calcium
channel blockers;
as second-line drugs, it is recommended to add long-acting nitrates, ivabradine, nicorandil,
or ranolazine according to heart rate, blood pressure, and drug tolerance;
Trimetazidine may also be considered as a second-line treatment;
in certain patients, depending on the level of comorbidity / tolerance, second-line drugs can
be used as first-line drugs;
β-blockers should be considered first in asymptomatic patients with a large ischemic area
(>10%).
β-Blockers (BABs) are effective antianginal agents that relieve symptoms, increase
exercise tolerance, and reduce the consumption of short-acting nitrates [12]. They reduce the need
for oxygen by reducing heart rate, blood pressure and myocardial contractility. Perfusion of
ischemic areas is improved by prolonging diastole (ie, perfusion time) and eliminating coronary
steal due to increased vascular resistance in non-ischemic areas.
Commonly
used β1-blockers with proven high antianginal efficacy are metoprolol,
atenolol, and bisoprolol. To achieve an antianginal effect during the day, β1-blockers with long-
term blood circulation in the plasma (for example, bisoprolol) or dosage forms that maintain the
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plasma concentration of the drug (for example, metoprolol CR) are prescribed. To maintain the
same concentration of atenolol in the plasma (half-life 6-9 hours), dosing twice a day is acceptable,
but it should be remembered that the duration of the β-blocking effect increases with the increase
in the dose of the drug. . The effect of beta-blockers in stable angina can be considered only if their
use achieves a clear effect of beta-adrenergic receptor blockade. To do this, it is necessary to keep
the heart rate at rest in the range of 55-60 beats / min. More precisely, the degree of blockade of
β-adrenergic receptors achieved can be evaluated by an exercise test [8].
A meta-analysis examining the effect of various beta-blockers on mortality showed a
significant reduction in mortality with long-term use after myocardial infarction. Based on these
data, it has been suggested that beta-blockers may also have a cardioprotective effect in patients
with stable coronary disease. However, this was not proven in a placebo-controlled trial [13].
Large studies on the effectiveness of beta-blockers for stable angina - APIS [14] and TIBET
[15] - did not show a significant difference in results between patients treated with beta blockers
or calcium channel blockers, nifedipine or verapamil. These studies confirmed the beneficial
antianginal properties of β-blockers, but did not answer whether treatment changes the prognosis
of patients with stable angina.
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