Atherosclerosis (atherosclerosis, grech, athere gruel + sklerosis consolidation, hardening) — extended hron, the disease which is characterized by specific damage of arteries of elastic and muscular and elastic type in the form of focal growth in their walls of connecting fabric in combination with lipidic infiltration of an internal cover that brings to organ or (and) to the general circulatory disturbances. Depending on degree And. and its localizations in vascular system form certain clinical manifestations, a part from which is allocated in separate syndromes and even nosological forms (e.g., coronary heart disease).
Diseases which cornerstone is And., are the most frequent reasons of disability and mortality in the majority of the countries of the world. Distribution And. in the countries of Europe and Sowing. America is much wider, than in the countries of Africa and Asia; in the states with a high economic potential frequency And. it is more, than in underdeveloped countries.
Statistics And. it is complicated since epidemiological inspections of the population supply with the information only on clinical displays of a disease that does not match data on its frequency on materials of openings.
- 1 HISTORY
- 2 The AETIOLOGY AND the PATHOGENY
- 3 PATHOLOGICAL ANATOMY
- 4 AGE EVOLUTION of ATHEROSCLEROSIS
- 5 CHANGES of the HEMODYNAMICS AT ATHEROSCLEROSIS
- 6 The CLINICAL PICTURE AND DIAGNOSIS of ATHEROSCLEROSIS of VARIOUS LOCALIZATION
- 7 Radiodiagnosis of atherosclerosis
- 8 The FORECAST
- 9 PREVENTION
- 10 TREATMENT
- 11 Bibliography
In 1755 A. Haller for designation of the centers of adjournment of fatty masses in a wall of arteries offered the term «atheroma», and in 1761 to Morganyi (G. Century of Morgagni) and after Kryuvelye (J. Cruveilher, 1829) described pathological changes of arteries in the form of consolidation of their walls. In 1833 Mr. J. F. Lobstein entered the concept «arteriosclerosis» including processes, various on the etiology and a pathogeny, the general for which there were sclerous changes, a thickening and disorganization of a vascular wall. In 1892 R. Virchow offered the term «endarteriitis deformans nodosa», having emphasized with it the inflammatory nature of a disease, involvement in process of an internal cover of a vascular wall with deformation of the last and the focal (nodal) nature of process. The term «atherosclerosis» was offered in 1904 by F. Marchand. This term was widely adopted since successfully emphasized a combination of changes inherent to a disease in walls of arteries: adjournment of kashitsevidny fatty masses and development of connecting fabric in a wall of arteries. With introduction of this term, after emergence of the first experimental works of H. N. Anichkova and S. S. Halatov and subsequent researches H. N. Anichkova, there was an allocation And. in an independent form from the collective concept «arteriosclerosis».
The AETIOLOGY AND the PATHOGENY
for more than 100 years were offered various theories of development And. The theory of a dyscrasia of Rokitansky (K. Rokitansky, 1850), on a cut the prime cause of all changes are deposits of fibrin in a vascular wall and on its surface, not widely adopted in the middle of the 19th century, was put again forward in the fifties 20 century by Dyyugid (J. Century of Duguid, 1946). Separate provisions found it confirmation in works of many authors. Meyer (W. W. Meyer, 1949), Bredt (H. Bredt, 1969) and other researchers as if revived R. Virchow's theory, recognizing primary at And. not disturbances of lipidic exchange, but early changes of a vascular wall. Lipids at the same time are considered not as the reason, and only as indicators of sclerous process in a wall of arteries. Thomas's theory (R. Thoma, 1886, 1923) considering And. as the compensatory and reparative phenomenon in response to loss by arteries of a muscle tone and elastic properties, it was partially supported by I. V. Davydovsky who carries And. not to medical, and to biological problems of age involution of an organism. According to I. V. Davydovsky, And. — «the problem is gerontological, the wide plan»; nosological essence And. in general it is rejected, and questions of its etiology and a pathogeny are transferred to the section of biological problems of gerontology. Most of clinical physicians does not divide this concept as detection of fibrous plaques at persons is younger than 15 — 20 years hardly can be regarded as manifestation of aging. However legitimacy of an identification And. and a lipoidosis of an internal cover of an aorta at children in itself it is called in question (A. P. Avtsyn, 1972). Nevertheless it is established that against the background of the general tendency to increase in life expectancy incidence And. increased and are surprised more and more young contingents of the population, especially male.
Among concepts there are origins And. the theory of cholesteric infiltration which is based on pilot studies of H had the greatest recognition until recently. N. Anichkova and S. S. Halatov (1912) and subsequent works of H. N. Anichkova and his schools. It was revealed that feeding to rabbits of high doses of cholesterol leads for a long time to development at them of a hypercholesterolemia and massive adjournment of cholesterol and its ester in an intima of an aorta. It was considered as experimental And. (see. Lipoidoses ) — the model of a disease coming to And. at the person as earlier it was shown that lipids in an internal cover of arteries at this disease are generally presented by cholesterol and holesterinester. However for receiving a holesterinoz of arteries at other animals, especially omnivorous (dogs, rats), one administration of cholesterol appeared insufficiently. The person has an obligate communication between exogenous cholesterol, a hypercholesterolemia, on the one hand, and expressiveness And., with another, no. Other versions of this theory allocate crucial importance not for exogenous cholesterol, but endogenous disturbances of its synthesis and assimilation or increase in the relation cholesterol / phospholipids . According to the infiltration theory of Page (J. Page, 1954) at And. there is a disturbance of passing of lipoproteins through a vascular wall, their delay in an internal cover to the subsequent release of lipids, preferential cholesterol. Reasons of this phenomenon: 1) change of composition of blood (hypercholesterolemia), increase in quantity of some lipoproteins; 2) disturbances of permeability of the most arterial wall.
Penetration of both big, and small molecules through an endothelium of an artery in its wall happens through intercellular intervals or cracks which open at stretching of an artery during a systole. Normal extent of opening of cracks is limited to the intercellular contacts and crossing points of an endothelium allowing penetration into not changed wall of arteries only of oxygen, waters, electrolytes, glucose, albumine and some lipoproteins necessary for a covering of metabolic requirements.
Elektronnomikroskopichesky research of an endothelium of arteries at And. revealed considerable swelling and lengthening of intercellular crossing points, excessive opening of intercellular cracks that leads to increase in filtering of substances from blood in a wall of arteries and causes penetration through an endothelium of large molecules and particles, including lipoproteins, chylomicrons, leukocytes. If filtration rate of lipids exceeds the speed of their washing away from an arterial wall drainage systems of an internal wall, then «atheroma» forms. At increase in intravascular pressure not only filtering of lipids in an internal cover increases, but also the probability of disturbances of a drainage at the expense of a prelum of vasa vasorum at restretching of an artery increases. Disclosure of intercellular cracks can result also from a peeling and a necrosis of endothelial cells at action of a complex antigen — an antibody, and also under the influence of amines, kinin, various enzymes and other factors.
New data of the theory, in a cut the crucial pathogenetic role is assigned to disturbances of lipid metabolism, Fredrikson's data (D. S. Fredrickson, 1967) with soavt, about five types of a hyperlipemia are; from them the second — the fourth are atherogenous. To distribution of the «lipidic» theory And., apparently, two circumstances promoted: a possibility of creation of the pilot model which is formally identifying Ampere-second the only pathogenetic factor — an exogenous hypercholesterolemia (that does this model convenient for studying), and availability of a research in clinical conditions of lipids of blood as possible factors of development And. (by analogy with a pilot model). As a result exchange of various lipids, however value of its disturbances is studied in detail for And. remains in many respects not clear. Despite emergence for the last 50 — 60 years of a huge number of researches, nevertheless it was not succeeded to develop not only universal, but even more or less acceptable theory of A. V a crust, time the histogenesis is more studied And., i.e. the nature of observed morphological changes, time and the sequence of their development whereas the etiology and a pathogeny of this disease remain not quite found out. It was considered to be that And. — the polyetiological disease, i.e. a number endo-and exogenous factors promotes emergence and development of process. However some convincing proofs that each of these «etiological» factors separately leads to development And., no. It is rather «risk factors» in development And., promoting its progressing or emergence of clinical manifestations.
In a crust, time consider that in development And. the following factors play a role.
1. Hypercholesterolemia (see), a hyperlipemia (see. Lipemia ), the Crimea is given the leading role in A. Odnako's etiology pathoanatomical researches do not confirm correlative communication between a hypercholesterolemia and expressiveness And. the person, also has a number of the data testifying against crucial importance of these factors in development And. at the person: a) excess of exogenous cholesterol in most cases does not lead at the person to development of a hypercholesterolemia; b) existence of a hypercholesterolemia is not obligate for the development expressed And.; c) cases heavy are known And. at persons with low level of lipids, including cholesterol, in blood; d) if the lipoidosis of arteries and the first fibrous plaques found at children's and youthful age are the first manifestation And., it is necessary to consider that the vast majority of children and young men suffers from disorders of lipidic exchange. Apparently, the lipoidosis of arteries should be considered as promoting, but not an obligate condition.
2. The increased arterial pressure irrespective of the reason of its increase is the factor strengthening development And., what is proved on extensive pathoanatomical materials. Strengthening of atherosclerotic process at an arterial hypertension is caused not only by changes in a hemodynamics, but also the increased accumulation in a vascular wall of acid mucopolysaccharides, preferential a hondroitinsulfata In and
Page 3. The great value in A. Prinyato's development is attached to hormonal factors to be that the diabetes mellitus promotes: to its development since in clinic diabetes is often combined with expressed And. and at diabetes there are disturbances of lipidic exchange. However studying of an aorta and coronal arteries of the persons who died of «pure» diabetes i.e. without combination to an idiopathic hypertensia or other diseases influencing the current And., showed that up to 50 years expressiveness And. at diabetes or is in the limits taking place at almost healthy faces which died from the accidental reasons or only slightly surpasses those. After 50 years And. at diabetes on the weight did not differ from that at the persons who died from And. and not having diabetes. It allows to assume that at persons of young age diabetes exerts insignificant impact on a current And., and at advanced age developing of diabetes can be caused And. the vessels feeding a pancreas, i.e. diabetes can be secondary in relation to A. Odnako many questions of interrelation And. and diabetes, in particular question of influence on development And. antidiabetic therapy, demand additional researches.
At the increased function of a thyroid gland (a hyperthyroidism, a thyrotoxicosis) clinical manifestations And. usually are absent, and anatomically And. it is expressed much more weakly. The hypothyroidism (an euthyroid craw, a myxedema), on the contrary, promotes development And., what is used in pilot studies. The great value is attached to sex hormones. If Influence of androgens on development And. not quite it is clear, are oestrogenic in an experiment and at patients reduce a hypercholesterolemia, increase coefficient phospholipids / cholesterol , reduce the content in blood of beta lipoproteids and slow down development cholesteric And. at animals. Explain these later development And., especially coronal arteries, at women and smoothing of distinctions in the frequency of defeat And. men and women in the senior age groups (after a menopause at women) or after castration.
Less accurate are data on hormones of an adrenal gland; their mediated influence through increase in arterial pressure is possible (Cushing's syndrome, Itsenko's disease — Cushing, a pheochromocytoma). It is known also that catecholamines lead to release of free fatty acids from fat depos; prostaglandin E 1 , on the contrary, suppresses this effect.
4. Social factors play a large role in A. Urbanization's development the population and increase of the stressorny and conflict situations connected with it, a psychological overstrain promote early emergence and bystry progressing, And., especially in coronal arteries. Wide spread occurance And., especially in economically developed countries, it is connected, apparently, not with character of food, and with increase of stressorny influences. Communication And. with stressful factors it is shown on the example of South Korea: at representatives of the poorest population of this country, the most affected by war, on opening constantly it was found And. (nevertheless expressed more weakly, than at Europeans) though key products of their food are rice and cabbage (meat, oil and milk are used seldom).
It is undoubted also that for development of clinical manifestations And., especially coronal and brain vessels, the stressorny situations connected with professional matter; conditions. Morphologically And. coronal vessels it is expressed stronger at persons of intellectual, than physical work, at residents of the cities, than at country people.
For development And. also the general life expectancy matters. In Sri Lanka, e.g., average life expectancy of men after elimination of malaria increased from 44 to 54 years and at the same time incidence and cardiovascular diseases mortality increased by 50%. Therefore Stamler (J. Stamler, 1961) carries And. to the diseases which are a consequence of social evolution.
5. Obesity and small physical activity also strengthen anatomic and clinical manifestations And. At persons corpulent which work is connected with low physical activity, And. an aorta and coronal arteries it is expressed much stronger, and heavy clinical manifestations And. meet at them several times more often, than at persons thin and physically active.
6. The role of smoking as etiological factor remains still not clear; in one pathoanatomical researches it is specified strengthening And. coronal arteries at smokers, in others — these data do not find confirmation. Perhaps, influence of smoking is more shown by disturbances of a regional blood-groove, than direct atherogenous action on a vascular wall.
In a crust, time there are also no reliable data about influence of quantity and duration of alcohol intake on an atherogenesis at the person, and experimental data are contradictory.
7. Representatives of various nationalities and ethnic groups have significant differences in turning And. However the comparative researches of chemical structure of an aorta at newborn Europeans and to a bow conducted by Maier (J. Century of Meyer, 19.66) et al., did not reveal any distinctions. The lipoidosis of arteries is expressed at various nationalities approximately equally, however time of manifestation and rates of development of fibrous plaques are subject to considerable fluctuations, and distinctions begin to be shown already with 2 — the 3rd decade of life. Perhaps, it is connected with influence of various environmental factors on reactivity of a vascular wall. Epidemiological researches A., carried out on the basis of pathoanatomical data, proved what at faces of the same or similar ethnic groups living in various geographical zones, I have? the place significant differences in expressiveness And.; at faces of various ethnic groups living in one geographical zone or in one city, expressiveness and rate of development And. are also various. Thus, apparently, both ethnic factors, and environmental factors exert impact on development And., however to define what is decisive, at the modern level of knowledge it is not possible.
8. Genetic, hereditary factors also play a role in a pathogeny And., but they are a little studied. Apparently, they have the known value for development of a disease at young age, and especially at men.
9. Disturbance of balance of coagulant and anticoagulative systems of blood, obviously, also promotes progressing And., as fibrinogen and fibrin are constant components of plaques.
The data stated above indicate exclusive complexity of a problem of a pathogeny And. and on the leading value of the disturbances of an arterial wall in it promoting accumulation in it of proteinaceous substances, lipoproteins, lipids with the subsequent development of connecting fabric. The reasons of this phenomenon remain unknown. Deviations in lipid metabolism promote development of process. Various endo-and exogenous factors can accelerate or slow down development And. In the course of age involution the probability of integration of separate above-stated factors increases, as defines steady progressing And.
Macroscopically distinguish the following types of atherosclerotic changes (in ascending order of their weight and the clinical importance).
1. Fatty strips or spots — sites of pale yellow color which do not tower over a surface of an internal cover sometimes merge with each other, contain the lipids clearly revealed at total coloring of a vessel by the paints revealing fats, in particular Sudan (Color tab. 1, fig. 1 and 2).
2. Fibrous plaques — whitish, sometimes as if nacreous or slightly gelatinous look, the intimas towering over a surface, most often the oval and roundish formations of various thickness and extent merging with each other to continuous fields that gives to an inner surface of a vessel an uneven, hilly look (Color tab. 1, fig. 2 — 4). Fibrous plaques contain this or that quantity of lipids in depth.
3. Fibrous plaques with an ulceration, hemorrhages and imposing of trombotichesky masses (fig. 4, 5, and Color tab. 1, fig. 5 and 6).
4. Calcification or an atherocalcinosis — adjournment sometimes a large amount of calcic salts in fibrous plaques (Color tab. 1, fig. 4). All these changes can exist at the same time in various combinations, giving big diversity and variability to all picture of defeat that is especially often observed in a ventral aorta at persons of the senior age groups.
There are certain patterns of localization of the first manifestations And. Before everything atherosclerotic changes in a type of lipidic spots and strips appear on a back wall of a chest aorta, in the place of an otkhozhdeniye of intercostal arteries, a bit later in a ventral aorta. However fibrous plaques arise in a ventral aorta earlier, and the quantity them here quickly increases. The most frequent localization of fibrous plaques is the field of bifurcation of an aorta, the place of an otkhozhdeniye of arteries, area of branchings, places of excesses, gyrose sites of vessels (e.g., a bend of an internal carotid artery, bends of a splenic artery), sites are higher than the place of narrowing (e.g., coarctations of an aorta), the place with roughnesses of an internal cover (e.g., sites of a syphilitic mesaortitis are higher). In these sites of vessels there can be various disturbances of a hemodynamics (delay of a blood-groove, disturbance of laminarity of a flow of blood, the strengthened pressure or blow of blood about a vascular wall or an uneven tension of a vascular wall in places of excesses), and also some features in a structure of a vascular wall (a thickening of an elastic framework in the field of branchings and an otkhozhdeniya of lateral branches).
The frequent place of emergence of atherosclerotic plaques are also the sites of an arterial wall which are exposed to continuous external mechanical influences, napr, initial department of the left coronal artery on the party, adjacent to the reduced myocardium or the sites of coronal arteries blocked by myocardial bridges. In a crust, time it is established that at development And. precedes lipidic infiltration process, so-called to a lipidic stage, to a cut first of all the focal, limited hypostasis of an intima which is found already at youthful age belongs; macroscopically it looks as the translucent site of oval or rounded shape of a gelatinous look, unsharply konturirovanny, with a diameter up to 1 cm, sometimes located among fatty spots separately, sometimes near them.
Microscopically fibrous structures and cellular elements of an internal cover on the limited site are diconnected by the liquid rich with protein and containing proteinaceous and lipidic complexes (fig. 1 and Color tab. 2, fig. 1). Further disintegration of proteinaceous and lipidic connections can lead to emergence of small amounts of free lipids. I. V. Davydovsky considered these earliest changes as a result of increase in permeability of a vascular wall. The proteins which are a part of edematous liquid can drop out in the form of fine-grained precipitated calcium superphosphate; at heavier changes the dropped-out threads and flakes of fibrin are visible. The amount of acid mucopolysaccharides in the main Substance is sharply reduced, they are depolymerized. Collagenic and elastic fibers also are involved in process; their swelling is observed, thinning, fragmentation, their contours become uneven, indistinct. Ability of elastic fibers to give fluorescence in UV rays changes, they are affected by elastase much easier. On the changed elastic fibers I. V. Davydovsky observed also adjournment of plasma proteins. As showed the elektronnomikroskopichesky researches, cellular elements presented in an internal cover of hl. obr. smooth muscle cells, in a zone of hypostasis can not change and only at considerable weight of process (and it is possible, its bigger duration) death are exposed.
Other manifestation of dolipidny changes is the strengthened synthesis, accumulation and polymerization in an intima of the acid, generally sulphated, mukopolisakharidny complexes that comes to light in the form of the centers of a metachromasia of the main substance of arteries (fig. 2, a). The sequence of these two processes can be various, they, apparently, can precede one another, arise independently from each other or at the same time. In a crust, time it is established that the acid mucopolysaccharides which are especially sulphated easily connect to beta lipoproteins of serum, forming with them strong complexes, i.e. the centers of accumulation of mucopolysaccharides are as if zones of fixing of beta lipoproteins. It should be noted, however, that concerning accumulation of mucopolysaccharides views of researchers disperse, and many consider that it is secondary in relation to a lipoidosis and that lipids can connect mucopolysaccharides.
Also flat pristenochny blood clots arising in various departments of arterial system and not changed internal cover (Color tab. 2, fig. 2) found usually only at microscopic examination on probably belong to dolipidny changes. Blood clots can consist of one thrombocytes, one fibrin or both of these components (fig. 2, b). In a crust, time it is established that such blood clots normal are constantly formed on a surface of an internal cover at people and animals, but, as a rule, quickly are exposed to a lysis. However sometimes a lysis is late, trombotichesky masses is exposed to an endotelization, the organizations or hyalinizations and give further rise to formation of an atherosclerotic plaque.
Two more types of changes which though do not belong literally to a dolipidny stage are, apparently, of great importance in the subsequent development of atherosclerotic changes, especially in coronal arteries of heart; It is, first, a muscular and elastic hyperplasia of an internal cover of arteries. In coronary arteries it begins already at children's age and consists in splitting and fragmentation of an inner elastic membrane and proliferation of unstriated muscles through ruptures of a membrane in an intima with formation of a longitudinal layer (Color tab. 2, fig. 3 and 4) here. Robertson (J. H. Robertson, 1960) found these changes in fruits of 14 weeks and is more senior, Doc (W. Dock, 1946) — at newborns; lipids did not contain in the changed vessels. Robertson did not refer these changes to pathological since there are no direct proofs of transition them in atherosclerotic plaques whereas Fangmen and Hellvig (R. J. Fangman, C. A. Hellwig, 1947), Mun (H. D. Moon, 1957) considered them as the earliest manifestations And., and Daud (A. S. Daoud, 1964) et al. — as preaterosklerotichesky changes. The last conclusion is, apparently, more correct as process has character, uneven on length of a vessel, therefore there are peculiar «pillows» surpassing thickness of the subject average cover and the emergence which is the favourite place in thickness further of atherosclerotic plaques. The most superficial departments of muscular and elastic pillows consist of fine collagenic fibers. Secondly, treat similar changes, perhaps, so-called rhythmic structures of an internal cover of an aorta which cornerstone focal, chaotic increase in elastic structures on border of internal and average covers with proliferation of smooth muscle elements and adjournment here of lipids in the form of the parallel alternating strips (Color tab. 2, fig. 6) also is further, reminding traces of a surf on the sandy coast that it, obviously, is caused by pulse wave of the movement of blood (fig. 3).
Further in these parts there are typical atherosclerotic plaques.
Lipidic stage And. consists in emergence on an intima of arteries small (0,5 — 1 cm) spots or strips of yellowish color which are not towering over a surface of an internal cover (Color tab. 1, fig. 1 and 2).
The first lipidic spots appear already at early children's age, they can be found approximately in 50% of children aged till 1 year, and later almost in all. They are localized in a zone of an aortal ring, in a hem on site of an overgrown arterial channel and about mouths of intercostal arteries at this time (fig. 4, a). The area occupied with a lipoidosis in an aorta considerably increases in youthful age, extending with chest to a ventral aorta where separate spots can merge with each other to continuous fields and occupy up to 60% of the space of an intima of an aorta (fig. 4, b); in an echo time (after 10 years) the first lipidic spots in coronary arteries appear.
Microscopically: the lipoidosis is presented by two processes. The first of them — emergence of lipids in cytoplasm of cells of an intima., in so-called cells of Langkhans (fig. 5, a). In a crust, time it is established that these cells have a myogenetic origin, at an elektronnomikroskopichesky research they have a cellular basal membrane, and in their cytoplasm myofilaments, i.e. the elements characteristic of unstriated muscles and absent at mononuclear cells of the fabric or hematogenous nature are found. These cells possess the main role in ensuring structural and functional safety of a vascular wall; many authors consider that they form collagenic and elastic fibers, synthesize the main substance of a vascular wall and take active part in her metabolism, and one of the major power mechanisms is utilization of the β-lipoproteins arriving from blood.......... The number of lipidic inclusions in cytoplasm of smooth muscle cells can vary over a wide range — from single small inclusions with gear contours on diffraction patterns at the beginning of process before full filling of a body of a cell with formation of ksantomny cells or, more precisely, than myogenetic foamy cells (Color tab. 2, fig. 5 and 6). Drops of lipids have 2 microns a diameter; on diffraction patterns have an appearance of a vacuole, an okra - the wife a double membrane, or homogeneous inclusions, hg of the having membranes. Sometimes it is possible to see drops of lipids also in tanks of an endoplasmic reticulum. The last has the underlined drawing that can be considered as manifestation of the increased metabolic activity. In big lipidic spots treatment of intertsellyulyarny spaces is observed by the liquid containing albumine of plasma, ß lipoproteins which easily come to light by an immunofluorescent method. At hard proceeding process also threads and flakes of the fibrin which is located between the cells overloaded with lipids are found here. Further, if the cause which caused accumulation of lipids in myogenetic cells of an internal cover is not removed the last perish, and fatty masses passes into surrounding intercellular space (fig. 5, and Color tab. 2, fig. 6).
Other process of a lipoidosis defined microscopically — adjournment of free lipids (perhaps, partially in the form of lipoproteins) in. an internal cover of arteries with diffusion treatment and sometimes as if its bogging on a bigger extent (Color tab. 2, fig. 7) that is observed at children's and youthful age.
Apparently, this early lipoidosis is reflection of features of exchange of a vascular wall in it, age, and, undoubtedly, there are ample opportunities of its involution. Such lipoidosis is rather physiological, than pathological phenomenon. Besides, fibrous plaques always have limited character that also demonstrates that extensive fields of a lipoidosis generally are exposed to involution and only partially are a source of further development of atherosclerosis.
The endothelium at the person, apparently, does not play a significant role in formation of lipidic spots. Sometimes in its cytoplasm separate lipidic inclusions are visible, but their emergence can be considered as a result of passing of lipids of blood to a vascular wall. In the conditions of an experiment (feeding by an animal of the hydrogenated piririma oil) R. I. Sokolova and V. I. Metelitsa in the first days of an experiment along with change elastics observed sharp swelling and vacuolation of an endothelium of an aorta without adjournment of lipids (fig. 6) that, perhaps, is reflection of reaction of an endothelium to the increased maintenance of lipids in blood.
Histogenesis of a fibrous plaque. Each of the above described types of changes (focal hypostasis of an internal cover, a mural thrombosis, lipidic spots) separately or in a combination with each other can lead to formation of a fibrous plaque. Focal hypostasis of an internal cover, obviously, can undergo involution, without having left behind any traces. On the other hand, fabric structures in this area can undergo disintegration. At the same time metabolism of muscle cells is broken (that leads to accumulation of lipids in them), on a surface of an internal cover in this place from a blood flow can settle thrombocytes and drop out threads of fibrin. So fibroplastic process with the subsequent focal formation of connecting fabric begins, in a cut the described cycle of disturbances is repeated. In some plaques it is possible to find traces of these repeated disturbances, the immured remains of fibrin (fig. 7 and Color tab. 2, fig. 8). The organization of pristenochny deposits of fibrin can also be a basis for formation of a fibrous plaque especially as in the subject fabrics at the same time metabolic disturbances in cells and interstitial substance of an intima also take place. Limited hypostasis of a wall and a mural thrombosis can exist separately or be combined with each other, developing in various sequence, and also to be combined with a lipoidosis that in a bigger degree promotes formation of fibrous plaques.
Former unconditional recognition of lipidic spots the only initial type of the changes which are taking part in formation of fibrous plaques in a crust, time is called by a number of authors in question, and nek-ry in general is rejected. Apparently, nevertheless it is possible to consider that lipidic spots, in any case part of them, are not exposed to involution and turns into fibrous plaques. Excess accumulation of lipids in smooth muscle cells can be connected with various circumstances: the excess maintenance of lipids or unusual structure them in blood serum, the broken ability of cells to utilize the arrived lipids or a combination of these factors. Further progressing of a lipoidosis is caused, apparently, the fact that the reasons which caused it were not eliminated and continue to have effect, or the fact that the center of a lipoidosis arose in a zone of the above described dolipidny changes. It is spoken well by reduction or total disappearance of oxidizing enzymes, malate - and palmitatedehydrogenases in a zone of initial lipidic accumulation. Oppression of oxidizing enzymes is followed also by reduction the ATF-aznoy of activity connected with transport, accumulation and probably metabolism of lipids. Elektronnomikroskopichesky researches showed that as soon as smooth muscle cells begin to accumulate lipids, reduction of the ATP-ase connected with membranes in comparison with the ATP-ase connected with a myosin though the last also is reduced is observed. Watts (H. F. Watts, 1971) suggests that ATP-ase participates in processes of activation of fatty acids before their oxidation; decrease in its activity breaks this process that in turn leads to disturbance of metabolism of myogenetic cells, and they lose spo a sobnost to utilize the arriving fats. An analogy between the fatty dystrophy of smooth muscle cells observed in myometriums or in nodes of leiomyomas and accumulation of fats in myogenetic cells of an internal cover is drawn. Further the cells overloaded with lipids perish and lipids pass into surrounding fabrics where they are located in the main substance and along elastic fibers. The released extracellular lipids, proteins, especially the fibrinogen which is impregnating a plaque, the dropped-out fibrin have the fibroblastichesky, sclerosing effect which is expressed in infiltrations of this area lymphoid cells, fibroblasts, a small amount of polymorphic leukocytes, fabric and hematogenous monocytes and in increase in amount in the beginning of argyrophil, and then collagenic fibers that is early observed on diffraction patterns both at the person, and in an experiment. Around the center of a lipoidosis there is a zone of the young connecting fabric rich with the cellular elements, acid mucopolysaccharides which are again formed by vessels collagenic and, in smaller number, elastic fibers, edges crawls over a zone of defeat, surrounds it, separates from a gleam of a vessel. Elastic fibers in a plaque are presented by the thin, randomly scattered in its thickness fibrils oriented preferential along a longitudinal axis of a vessel. They easily are exposed to dystrophic changes and disintegration that is expressed in weak and their uneven colourability, swelling, fragmentation, roughness of contours etc. Often in surface layers of a plaque the amount of elastic fibers is especially high and they can form a continuous strip here.
Availability of defective elastic fibers in a plaque promotes its calcification (see below). Collagenic fibers in a plaque also easily are exposed to dystrophic changes, disintegration and a hyalinosis. The released lipids are exposed to secondary phagocytosis by macrophagic cells and monocytes and, apparently, partially through again formed vessels are carried away with a blood flow, i.e. the phenomena of a delipidization of a plaque take place. In process of maturing of connecting fabric the quantity of cellular elements is reduced, collagenic fibers become thicker, are hyalinized and there is a typical fibrous plaque consisting of the rough connecting fabric poor in cellular elements which is often hyalinized on a big extent from elastic fibers and this or that number of fatty masses with crystals of cholesterol in the center.
Atherosclerotic changes at a stage of a fibrous plaque are practically not exposed to involution as process of a delipidization is not followed by reduction of the area occupied with fibrous plaques. However the last become more flat, act in a gleam of a vessel less that has the known value in improvement of a hemodynamics. On the other hand, in plaques in which there is a process of a rassasyvaniye of lipids the strengthened adjournment of salts of calcium is quite often observed.
Development of atherosclerosis can temporarily stop, but it is more often steadily progresses though the speed of increase of process can be various. There are new plaques, they merge to continuous fields, in a tire of old plaques lipids can be postponed again or it becomes impregnated with liquid rich with protein that leads to new changes. On a surface of fibrous plaques or in deepenings between them settle thrombocytes and the mass of fibrin which will be organized, endotelizirutsya drop out, promoting thereby increase of process, giving it considerable diversity. The known value in progressing of atherosclerotic process is played by hemorrhages from again formed vessels of a plaque which often have a structure of thin-walled sinusoid. These hemorrhages arise irrespective of existence of dystrophic, atheromatous and ulcer changes in a plaque. Their traces in the form of deposits of hemosiderin are found in the majority of fibrous atherosclerotic plaques even in persons of young age. Being secondary changes, hemorrhages at the same time promote further progressing And., as are followed by an exit in fabric of lipoproteins and proteins of plasma, including fibrinogen.
If originally accumulation of lipids was plentiful, then the atheromatosis — as a result of death of lipophages and release of a large number of lipids in surrounding fabrics with their necrosis is possible; the cavity filled with the fatty masses and a fabric detritis, separated from a gleam of a vessel by a thin layer of connecting fabric is formed («a fibrous hat», fig. 8). The histochemical analysis of lipids shows that they include the phospholipids which are located usually on peripheries, esterified cholesterol, crystals of cholesterol and in much smaller quantities free fatty acids, sphingomyelin, unsaturated ethers of triglycerides, lecithin, cephalin, phosphoglycerides.
Circulatory disturbances in plaques, disintegration of lipophages and fabrics, infiltrirovanny fat, the necrosis and sequestration of a fibrous tire lead to an ulceration of a plaque with loss of atheromatous masses in a gleam of a vessel, stratifying of edges of an ulcer blood, extensive imposings of trombotichesky masses on an ulcer surface (fig. 9 and Color tab. 1, fig. 6) that sometimes leads to closing of a gleam of a vessel. Hit of an atheromatous detritis in a blood flow leads to embolisms in distal departments of a blood channel; in embolic masses it is possible to see crystals of cholesterol. Healing of ulcers happens by education on their surface of a pellicle of fibrin, edges is exposed to the organization and an endotelization from edges of defect.
Hemorrhages in a plaque, its ulceration, formation of trombotichesky imposings — all this combines the general concept «the complicated changes» and testifies to the heavy, progressing current And.
In the hyalinized, dystrophic and necrotic fabrics, in a fatty detritis, to sites of the changed elastic fibers there is an adjournment of salts of calcium. It is possible to allocate three types of calcification at And.
1. In the presence of atheromatous disintegration calcification of plaques happens as formation of the crystal center, subjacent plaques, in the place of formation of an atheroma (fig. 10). At the same time in the fine-grained kashitseobrazny weight consisting of proteinaceous substances, crystals of cholesterol, drops of neutral fats and fatty acids deposits of lime, in the beginning in the form of small grains, then merging in large conglomerates (Color tab. 2, fig. 9) appear. Knaruzhi from this center lays the salts of calcium connected with organic matter of a vascular wall, apparently, with mucopolysaccharides. In certain cases deposits of salts of calcium in a plaque merge with those in an average cover.
2. Adjournment of salts of calcium in the form of separate grains or glybok in the field of a tire of a plaque. In process of progressing of process continuous deposits which have an appearance of a guard or the lamina lying at top of a plaque are formed here.
3. Diffusion treatment of fabric the small motes or grains of salts of calcium which are located along again formed elastic fibers. At the same time the massive center of calcification in the basis or in a tire of a plaque is not formed. Adjournment of salts of calcium in a plaque is connected first of all with changes of the elastic fibers which are its part. Swelling, fragmentation, destruction of elastic fibers in a plaque constantly take place. Destruction of elastic fibers is followed by release and accumulation in a plaque of the acid sulphated mucopolysaccharides (hondroitinsulfata And yes C), having affinity to salts of calcium and easily connecting them. Besides, in young fibrous plaques in general there is a large amount of acid mucopolysaccharides that creates conditions for adjournment of salts of calcium. An accessory factor is disintegration of fatty substances with release of fatty acids which connect salts of calcium with formation of insoluble calcium soaps. Ability to connect calcium also proteins of plasma have, and a part of calcium is here in the connected state. At transudation in a plaque of proteins of plasma the last, especially fibrinogen and the dropping-out fibrin, can also connect calcium and be inlaid with salts of calcium. In particular, an opportunity is not excluded that formation of «guard» of lime on a surface of a plaque is connected, not only with existence of a layer of elastic fibers here, but also with treatment of fabrics blood proteins and with dystrophic changes in a tire of a plaque and adjournment of salts of calcium.
Calcification of the second and third type also, apparently, is connected with disturbances of properties of the elastic fibers which are a part of a plaque.
Fibrous plaques, the complicated changes, calcification will combine yutsyatsya under the general name of the «towering» changes, in difference «from pure» a lipoidosis, at Krom lipidic spots do not act over a surface of an internal cover. Though at And. the main changes develop in an internal cover, the average cover is also involved in process. It occurs owing to a number of circumstances. First, time arisen fibrous and furthermore the calcinated plaque puts purely mechanical pressure upon an average cover of an artery; secondly, the thickened, changed intima is a barrier on the way of diffusion of nutrients and oxygen, the hypoxia of an average cover is a consequence of what. Adams (C. W.М. Adams, 1967) it was shown that it leads to decrease of the activity of tetrazoliyevy reductase, ATP-ase and esterazny activity in smooth muscle elements of an average cover; the observed at the same time increased activity of a lactate dehydrogenase as the phenomenon compensatory or adequate to a hypoxia, has, apparently, the insignificant effect as is not followed by strengthening OVER — H2-reduktaznoy activities and cannot play a significant role in transport of electrolytes; thirdly, the phenomena of a nonspecific inflammation extend to an average cover, it is penetrated by again formed vessels and infiltrates from lymphoid, histiocytic and fibroblastichesky elements (fig. 11). All this combined leads to an atrophy and thinning of an average cover, to destruction of its elastic framework, development instead of it fibrous fabric, defective in the functional relation. At the same time here extensive deposits of lime on the course of the destroyed elastic plates of an average cover of an aorta or an inner elastic membrane of arteries of muscular type are observed. In vessels of average and small caliber (renal, mesenteric, coronary, out of - and intracranial) massive fibrous plaques lead to narrowing of a gleam, sometimes very considerable (fig. 12), with disturbance of blood supply of appropriate authorities up to its full switching off with formation of ischemic heart attacks.
Features of defeat of separate vessels
Aorta most is surprised in belly department though the lipoidosis and in bigger quantity appears purely earlier in a chest aorta. It, according to a number of authors, demonstrates that not all lipidic spots undergo further fibrous transformation. The lipoidosis in an aorta is usually expressed much stronger, than in other vessels; the area occupied by him reaches on average by 30 years of life 20% of a surface of an intima at men and 30% — at women whereas in other vessels does not exceed 4 — 5% of a surface of an internal cover. The complicated changes, and also calcification arise in a ventral aorta much earlier and reach bigger expressiveness. Frequency and especially extent of ulcerations in an aorta, especially in belly, considerably big, than in other arteries, napr, in coronary and renal where this type of changes occupies very small space. In an aorta in much bigger degree, than in other vessels, positive correlation between the extent and expressiveness of changes and age takes place.
As a result of destruction of an elastic framework the gleam of an aorta can extend, diffuzno or on certain sites, with formation of aneurisms of various sizes, sometimes with a rupture of the last in surrounding fabric (see. Aortic aneurysm ).
Quite often there are extensive trombotichesky imposings on an inner surface of aneurism (fig. 13). In the field of ulcerations penetration of blood between layers of a vascular wall with its stratification on a considerable extent and development of the stratifying aneurisms is possible (see. stratifying ). As a result of these changes length, width, weight of an aorta with heavy atherosclerotic changes is always more, than not changed or a little changed aorta. At the age of 70 — 80 years at 1 — 2% of men and 2 — 3% of women atherosclerotic changes in an aorta are absent or are limited only to a lipoidosis.
Coronary arteries at various people are surprised extremely unevenly. In the same age group it is possible to observe not changed or a little changed arteries and arteries with sharply expressed changes; therefore correlation is expressed much more weakly with age, than in an aorta. The muscular and elastic layer in coronary arteries is very developed, and, perhaps, early emergence here of atherosclerotic changes is connected with it.
The lipoidosis in coronary arteries is usually expressed poorly, and its area does not exceed 3 — 4% of a surface of an internal cover; ulcerations also, as a rule, occupy the small space (apprx. 1% of a surface of an intima). On the contrary, calcification is characteristic of coronal vessels and, apparently, plays a significant role in development of coronary insufficiency. Calcification of atherosclerotic plaques is the prevailing type of this type of changes here, preferential proceeds on the first type and is often combined with calcification of an inner elastic membrane. The centers of calcification in separate plaques progress, merge with each other to extensive fields, and sometimes the coronary artery on a considerable extent turns into a dense calciphied tube. From three main branches of coronary arteries atherosclerotic changes before everything arise and reach the greatest development in a front interventricular branch of the left coronary artery and in the right coronary artery (fig. 14), in the bending-around branch the area of defeat is much less. Frequency of stenoses in three main branches of coronary arteries has a feedforward with expressiveness of calcification: the area of calcification in a front interventricular artery exceeds that in two other arteries twice, and narrowing of a gleam more than for 50% is observed in this artery twice more often, than in two other branches. If there is an uneven development of arteries, then the most expressed changes are observed in the most developed arterial branch, i.e. in that, edges bears the greatest functional load. The first fibrous plaques usually appear in the most initial departments of a front interventricular artery, further they are most expressed in an initial third or a half of an artery where the circular arrangement of the merging plaques stretching on a considerable extent on a longitudinal axis of a vessel whereas in distal departments of change are usually limited to separate plaques is often observed. Participation of pristenochny deposits of fibrin between plaques in progressing of process is especially characteristic of coronary arteries. Thrombosis of coronary arteries as showed studying of serial sections, usually arises on site a rupture of a fibrous tire of an atherosclerotic plaque.
At the persons who died of coronary insufficiency or had a myocardial infarction, And. arteries it is expressed much stronger, than at the persons who were not suffering during lifetime from coronary insufficiency. Already aged up to 40 years 100% of faces of the first group in coronary arteries have towering changes whereas in the second group even aged after 60 years at 2 — 4% of persons of change in coronary arteries are absent. The area of the towering changes at the last approximately twice smaller, and a stenosis of coronary arteries with narrowing more than 50% of a gleam of a vessel occurs 9 — 10 times less often, than at faces of the first group. There is a clear distinction in expressiveness coronary And. at persons of physical work and at persons whose work is connected with small physical activity; at the first the area of the towering changes considerably smaller, stenoses of coronary arteries, a myocardial infarction and postinarktny hems meet less than at the second. At the persons having obesity, atherosclerotic changes in coronary arteries are also expressed stronger, than at thin, however influence of obesity affects much more weakly, than low physical activity. Persons, smokers have tobacco, in a large number, calcification at coronary And. it is expressed stronger.
Vessels of a brain. According to data A. N. Koltover with sotr., much more often and heavier extracranial departments of arteries are surprised, at the same time in carotid arteries the percent of defeat is several times higher, than in vertebrata. It is less often observed And. vessels of the basis of a brain and extremely seldom atherosclerotic changes of intracerebral vessels and vessels of a konveksitalny surface of a brain meet. In extracranial departments of carotid arteries (fig. 15) of the area of atherosclerosis first place is won by a sine of an internal carotid artery, the second — the general sleepy, the third — a bend of an internal carotid artery; the trunk of an internal carotid artery is involved in process extremely seldom. The same patterns of localization are noted in the frequency of atherosclerotic stenoses. From different types of changes fibrous plaques prevail; occlusion and the complicated defeats (an atheromatosis, hemorrhages in a plaque, pristenochny blood clots) are found in small percent of cases on comparison with stenoses and are, as a rule, localized in a sine of an internal carotid artery. Preferential localization of calcification — a bend of an internal carotid artery.
The isolated stenosing plaques in the place of their otkhozhdeniye from subclavial arteries are characteristic of extracranial departments of vertebral arteries. Much more rare, approximately with an equal frequency, the trunk and a siphon of vertebral arteries are surprised. Occlusions (trombotichesky and netrombotichesky) in extracranial departments of vertebral arteries are found seldom, their localization — a bend, is more rare proximal departments. The complicated changes (an atheromatosis and hemorrhages in a plaque) meet in a small amount of cases. Only in extracranial departments in small percent of observations (approximately with an equal frequency in carotid and vertebral arteries) rather rare forms of pathology of arteries — lengthening, crimpiness and excesses at an acute angle which, in opinion A. N. Koltover and N. V. Vereshchagina, arise in connection with age changes at the persons having a hypertension come to light. Perhaps, these changes are connected also with an atherosclerotic stenosis of proximal departments of vessels, about the Crimea they are quite often combined. Their preferential localization, unlike all types of atherosclerotic changes, in a trunk of an internal carotid and vertebral artery before an entrance to a skull. In vessels of the basis of a brain And. it is expressed in much smaller degree, than in extracranial. Most often changes in a type of the plaques isolated fibrous, sometimes stenosing are found. Symmetry of damages of pair arteries is characteristic. Among intracranial arteries internal carotid arteries and a basilar artery are surprised more often, the second place is taken by damages of average brain and vertebral arteries, less often back and front arteries of a brain are involved in process. In intracerebral vessels And. most often meets in arteries of subcrustal nodes, a thalamus and the varoliyevy bridge in the form of fibrous plaques, is more rare than a lipoidosis.
Persons with disturbances of cerebral circulation have a degree and prevalence of atherosclerotic changes of vessels of a brain are expressed much stronger. A large number of vessels which gleam is quite often stenosed by multiple plaques is involved in process; considerably the number of the complicated changes, and also fibrinferments of separate vessels increases. However and in these cases big variability of atherosclerotic changes is noted. Severe defeats of extracranial departments of carotid and vertebral arteries prevail, it is frequent with formation of the continued occlusive blood clots in carotid arteries. Among vessels of the basis of a brain averages brain suffer more often; basilar and back brain arteries are surprised less often.
Renal arteries. In renal arteries the main - changes arise in the field of mouths. The main type of changes are fibrous plaques; the complicated changes and calcification meet seldom, and the area occupied by them is usually small. Zones of branching are surprised seldom, distribution of atherosclerotic changes insignificant. The right and left arteries are surprised to the same extent. There is a direct strongly expressed correlation between the area of atherosclerotic changes in a ventral aorta and frequency of stenoses of the main arteries of kidneys. At the persons who had arterial hypertension, the frequency of stenoses of renal arteries with narrowing of a gleam for 70 — 75% is higher, than among persons with standard arterial atmosphere pressure, i.e. correlative communication between arterial hypertension and narrowing of renal arteries is positive and sharply expressed (a correlation coefficient + 0,81). In additional arteries of kidneys (they meet approximately in 30% of cases) atherosclerotic changes are expressed more weakly, and stenoses are observed much less often.
AGE EVOLUTION of ATHEROSCLEROSIS
Data on age evolution can be obtained only on the basis of studying of pathoanatomical materials since no other methods give the chance to define the beginning of atherosclerotic process and its further evolution. The data given below are collected in various geographical zones of the USSR; they are received as a result of studying of 10 thousand aortas and coronary arteries (A. M. Vikhert, V. S. Zhdanov and E. E. Matova, 1970).
In a ventral aorta atherosclerotic changes are available for all dead 10 years irrespective of age are more senior. At the age of 10 — 19 years approximately in 16% fibrous plaques are found, and after 50 years fibrous plaques in an aorta meet in 95 — 99% of cases. The complicated changes and calcification in an aorta of men appear usually in the third decade of life, at women — since fourth decade; after 60 years these types of changes meet more than in 50% of observations. Frequency of fibrous plaques, the complicated changes and calcification in an aorta of women is slightly less, than at men; at women in vessels only the lipoidosis is more often observed.
In coronal arteries at the age of 10 — 29 years atherosclerotic changes are found in persons less than in an aorta — approximately in 77% of cases, but fibrous plaques meet more often than in an aorta. After 40 years at 1 — 2% of the dead atherosclerotic changes are absent, 5 — 7% of persons have only lipidic spots, for the others — fibrous plaques. Calcification in coronal arteries meets from third decade of life, the complicated changes — from fourth decade. At men 50 years are more senior and 60 years are more senior than women calcification meets more than in half of observations, the frequency of the complicated changes does not exceed 25%. As the complicated changes, and calcification aged up to 70 years meet at men more often.
The total area of atherosclerotic changes of a ventral aorta occupying at the age of 10 — 19 years 12,4% of a surface of an internal cover men and 20,1% — at women, increases to 72% (both at men, and at women) at the age of 70 — 79 years; further average area, occupied And., does not increase. The largest space at persons aged up to 40 years is occupied by lipidic spots, after 40 years — fibrous plaques.
Lipidic spots at persons at the age of 10 — 19 years occupy 9,9% of an internal cover of an aorta men and 17,1% — women. The area them at men by 30 — 39 years increases to 20,2% then begins to decrease and by 80 — 89 years makes 2,9% of a surface of an internal cover. At women lipidic spots in an aorta occupy the largest space in 20 — 29 years (30,2%). Fibrous plaques at young age (10 — 29 years) occupy no more than 2,5% of a surface of an internal cover of an aorta. After 30 years the area them increases and by 70 — 79 years reaches 52% of an internal cover both at men, and at women. The area of the complicated changes and calcification at young age makes no more than 0,2 — 0,3% of an internal cover of an aorta. The area of the complicated changes increases at men to 9,7%, at women with age — to 5,7%. The area of calcification at men reaches 10,6% of an internal cover, women have 19,7%.
The total area of atherosclerotic changes of coronal arteries increases from 2 — 3% of a surface of an internal cover at men and women of 10 — 19 years to 60 — 62% at the age of 80 — 89 years. The prevailing type of changes in coronal arteries are fibrous plaques which at men are more senior than 20 years and women 30 years are more senior occupy the largest space. Lipidic spots in all age groups occupy no more than 3 — 4% of an internal cover. The area of fibrous plaques increases every decade of life. At the age of 10 — 19 years they occupy men 1,2% of an internal cover, in 80 — 89 years — 43,6%. At women up to 70 years fibrous plaques in coronal arteries occupy the smaller space, than at men. The area ‘the complicated changes changes a little with age and occupies no more than 0,4% of the space of an internal cover. The area of calcification increases from 0,2% at young age to 14,9% at men and 13,4% — at women is after 80 years.
Age dynamics and morphological features And. are caused by many factors that finds the expression in extremely big individual differences of degree of manifestation And. even in homogeneous group of people on age and a floor. In all groups the development progressing with age takes place And. in the studied vessels, however rates of development of atherosclerotic process are various. The heaviest And. it is observed at the persons who had a hypertension, coronary heart disease and at patients with a diabetes mellitus 50 years are aged more senior. E.g., almost healthy people who died on the eighth decade of life have approximately the same atherosclerotic changes as well as which died of manifestations And. in the fifth or sixth decade of life. It is least expressed And. at the persons who had a thyrotoxicosis, cirrhoses of a liver, hron, pneumonia, hron, a pulmonary tuberculosis. With increase in age of distinction in expressiveness And. between groups of persons, having various diseases, decrease. Quite significant differences in the studied groups attract attention. So, in a group of persons, died on the eighth decade of life, change of easy degree (the space of the towering defeats is occupied by no more than 15% of a surface of an internal cover in a ventral aorta) were noted in 4,8% of cases, average degree (the area of defeats is equal to 16 — 50%) — in 25,3% and heavy degree — in 69,9%; at almost healthy people these changes were noted respectively in 15,9; 39,1 and 45% of cases.
The given materials demonstrate that age dynamics And. has very essential distinctions; they are caused by a number of factors, in particular the factors connected with a floor, work, a condition of food, genetic premises. Value of age in development And. at the person it is very big, but it cannot be recognized as defining.
CHANGES of the HEMODYNAMICS AT ATHEROSCLEROSIS
the Nature of hemodynamic frustration at And. is defined by its localization, degree and extent of defeat of vascular system. In a stage of lipidic infiltration of an internal cover of arteries of disturbance of the general hemodynamics usually are absent since hydrodynamic conditions of a blood-groove are almost not changed. However already in this stage and more during formation of fibrous plaques due to change of reactivity of the struck vessels the passing arterial spasms leading to ischemia of appropriate authorities can be observed. Changes of vascular reactivity at And. (up to paradoxical angiospastic reactions to vasodilating physiological and pharmacological influences) quite often define acute disorders of organ blood circulation and in later stages of a disease.
Peripheric resistance to a blood-groove increases in places of localization of fibrous plaques. The general peripheric resistance at local defeats even large, napr, femoral, arteries significantly does not change, however it can be the consolidation of arterial walls increased at widespread Ampere-second. More frequent reason of increase in the general peripheric resistance at And. reflex increase in a tone of muscular arteries at localization of atherosclerotic defeat in an aorta and carotid arteries (barorecrptor reflexogenic zones) and in connection with reduction of minute volume in a phase of a decompensation of heart is at And. coronal arteries. It increases also at the nephrogenic arterial hypertension arising due to increase in activity of system a renin angiotensin in case of atherosclerotic damage of renal arteries.
Cardiac performance increases at increase in resistance to a blood-groove in an aorta, and also at caused And. arterial hypertension. It leads to the hypertrophy of a left heart usually moderate. At And. coronary arteries of heart with a macrofocal or focal and diffusion sclerosis of a myocardium sokratitelny activity of ventricles of heart (hl. obr. left) it is broken both at the expense of a degrowth of sokratitelny fibers, and at the expense of an asynergia of left ventricular reduction (see. Coronary heart disease ). Thereof the phase structure of a cardial cycle changes: the period of tension, a phase of asynchronous and isometric contraction are extended, the period of exile of blood from a left ventricle is shortened; speed of increase in intra ventricular) pressure often decreases, and end diastolic pressure increases. Besides, considerable disturbances of the general hemodynamics can develop in connection with disturbances of a cordial rhythm at ischemic damage of the centers of automatism and the carrying-out system of heart (see. Arrhythmias of heart , Heart block ).
Arterial pressure in the central vessels is most characteristic changes at And. aortas. At healthy people elasticity of an aorta plays an important role in formation of both systolic, and diastolic pressure. The motive energy of mass of the blood which is thrown out in an aorta at a systole of heart in connection with the peripheric resistance to a blood-groove partially is spent for heat effect and substantially transformed to a potential energy of pressure; an essential part of pressure energy at systolic stretching of an aorta and large elastic arteries turns into elastic tensile forces of arterial walls. The last process, minus some power losss on formation of heat, we will turn: in longer, than a systole, the period of a diastole pressure in vascular system is created by energy of elastic reduction of the stretched walls of an aorta, and the blood flow in vessels proceeds. At atherosclerotic damage of an aorta with its consolidation and reduction of elasticity systolic distensibility of walls of an aorta sharply decreases; thereof the share of systolic pressure turned into energy of elastic stretching of an aorta decreases, and the size of systolic pressure increases. If the cardiac muscle is not affected, then the increase in power of cordial reduction demanded for overcoming additional resistance in a rigid aorta also promotes increase in systolic pressure. Reduction of elastic forces of reduction of an aorta in the period of a diastole leads to decrease in diastolic pressure, sometimes very expressed. Thus, changes of arterial pressure at And. aortas are characterized by increase systolic, decrease diastolic and, the main thing, considerable increase of pulse pressure (a difference between systolic and diastolic pressure).
At many patients even at the expressed damage of an aorta diastolic pressure after all significantly does not go down and can even be a little raised (remaining, however, lower than 100 mm of mercury.). In some cases it is reached by increase of number of cordial reductions and shortening of a diastole. Preservation of normal values is more often and a nek-swarm increase in diastolic pressure are caused by reflex increase in a tone of peripheral arteries and increase thereof general peripheric resistance. However, unlike conditions with normal distensibility of an aorta, the gain of peripheric resistance to a blood-groove more affects the size of systolic pressure since the share of a motive energy of cordial emission transformed to pressure energy considerably increases, and transition of energy of systolic pressure to forces of elastic stretching of an aorta changes a little. Thereof characteristic for And. aortas growth of pulse pressure remains rather expressed and arterial hypertension has preferential systolic character.
Substantial increase of diastolic pressure is observed seldom and always demands a careful exception of an idiopathic hypertensia. Diastolic hypertensia at And. can cause the following reasons. 1. Dysfunction of baroreceptors of sinocarotid and aortal reflexogenic zones at considerable atherosclerotic defeat of carotid arteries and a chest aorta. In a complex system of stabilization of level of arterial pressure these receptors carry out function of a feed-back, providing those a bigger flow of the afferent impulsation braking a vasomotor center, and, therefore, that a bigger depressor effect than pressure stretching walls of an aorta and carotid arteries is more. So, in an experiment the break of the alarm system from baroreceptors of these zones leads to permanent increase in arterial pressure due to increase in a tone of peripheral arteries and growth of the general peripheric resistance to a blood-groove. 2. Dysfunction of a vasomotor center at the expense of his ischemia at atherosclerotic damage of brain arteries. 3. Hron, ischemia of kidneys at atherosclerotic damage of renal arteries. At the same time nephrogenic arterial hypertension like Goldblatt develops (see. arterial hypertension ).
Decrease in elastic properties of aortal walls at And. usually leads to an aortectasia. Since extent of defeat on length of an aorta is not identical, under the influence of blood pressure its local expansions — aneurisms are possible. Feature of geometry of the ascending aorta which walls have the greatest hemodynamic blow at a systole of heart, and also a tendency to bigger extent of defeat And. a ventral aorta cause also more frequent localization of aneurism in these sites and the big clinical importance of such aneurisms (see. Aortic aneurysm ).
Atherosclerotic narrowing of a gleam of an artery leads to pressure decrease on length of the struck vessel, subjects bigger, than extent of narrowing is more. At localization of atherosclerotic plaques in subclavial, humeral arteries or the deforming sclerosis and consolidation of walls of these vessels, and also during the narrowing of their gleam at the expense of an aortic aneurysm the size of pressure measured on a shoulder can differ considerably from the size of pressure in an aorta. At the same time asymmetry of sizes of pressure on hands is quite often noted. Big of the registered sizes reflects the size of the central pressure with a smaller error in such cases.
The regional blood stream is broken especially considerably at And. organ arteries. Distalny places of atherosclerotic occlusion decreases both linear, and rate of volume flow of a blood-groove. On Poiseuille's equation rate of volume flow of a blood-groove through the section of a vessel is proportional to the fourth degree of size of its radius. Thus, reduction of radius of a vessel twice at not changed difference of pressure between an aorta and capillaries leads to reduction of rate of volume flow of a blood-groove in the pool of the affected artery by 16 times. From here it is possible to expect that decrease in a blood-groove due to fibrous changes of an intima will be especially considerable at atherosclerotic damage of arteries of small caliber in which relative changes of radius are big even at the small sizes of a fibrous plaque. The actual decrease in a blood-groove distalny an atherosclerotic plaque can be even big, than it is provided by Poiseuille's equation, due to change of geometry of section of a vessel on the site of defeat. It leads to disturbances of laminarity of a blood flow, formation of turbulent turbulences and increase of power losss of a blood-groove on friction. On friction leads to additional power losss also decrease in elastic properties of the affected artery at a sclerosis of walls that is not considered by Poiseuille's equation.
At a circular arrangement of plaques in an artery, and also at sclerous consolidation of its walls one of the most important functions of a vessel — the active change of a gleam regulating change of inflow of blood depending on requirements of body is lost.
Degree of organ circulatory disturbances is not always proportional to degree of atherosclerotic occlusion of the bringing arteries and significantly depends on very tectonics of arterial network of the respective areas. E.g., broad anastamosing of pools of internal carotid arteries among themselves and with pools of vertebral and outside carotid arteries provides compensation of cerebral circulation even at considerable narrowing of a gleam of one of internal carotid arteries. At slow development of atherosclerotic defeat development of collateral blood supply of an ischemic zone is possible that quite often takes place, e.g., at And. arteries of extremities. The greatest changes of blood circulation are observed at And. arteries of bodies in which the type of arterial blood supply comes nearer to «final» i.e. at poor development of an interarterial anastomosis, especially if formation of a plaque happens quickly.
Reduction of speed of a blood-groove and disturbance of structure of an intima of arteries in a zone of defeat are the main premises to a thrombogenesis in case of increase in coagulative properties of blood (see. Thrombosis ). Frequency of tromboembolic episodes is explained by it at And., the bodies leading to heart attacks and the persons which are quite often proximate cause of death suffering And.
The CLINICAL PICTURE AND DIAGNOSIS of ATHEROSCLEROSIS of VARIOUS LOCALIZATION
On the classification offered by A. L. Myasnikov (1955, 1960) during atherosclerosis two periods were allocated: initial (designated as preclinical) and the period of clinical manifestations. Basic significance for development of ways of early diagnosis was attached to allocation of the first of them And. and holding timely treatment-and-prophylactic actions. Neurovascular disturbances in the form of bent to the general or regional arterial spasms, a hypercholesterolemia and change of content of phospholipids and lipoproteids with disturbance of fractional composition of the last were specified as criteria for recognition of the preclinical period. However these disturbances as specified A. L. Butchers, «do not speak, of course, about existence yet And. also can pass, without having led to atherosclerotic changes». In the period of clinical manifestations three consecutive stages differed: ischemic (small dysfunctions of bodies due to reversible dystrophic changes in them called by ischemia); necrotic, or trombo-necrotic (the clinical symptoms caused by focal small or large necroses in bodies various are characteristic of different localizations And.), and fibrous, shown depression of function of the struck bodies due to development in them cicatricial changes with an atrophy of a parenchyma. It is obvious that the stated stages characterize degree connected with And. defeats of bodies, but not a stage of development And. as general disease what also A. L. Myasnikov pointed to.
In essence, A. Odnako's complications of other, best classifications of atherosclerosis were classified it is not offered yet. At the same time it is known that extent of organ disturbances not always corresponds to extent of atherosclerotic damage of the corresponding arteries; development of heart attacks in bodies (a necrotic stage) at the minimum damage of the bringing arteries is possible and without the previous ischemic stage.
During the approach to And. as to a disease of all organism that section of classification of A. L. Myasnikov is of clinical value, in Krom it is reflected, according to views of H. N. Anichkova, waviness of anatomic changes in vessels — change of phases of accumulation of lipids in walls of vessels and washing away of lipids. According to these processes are allocated a phase of progressing And. (active), phase of stabilization And. (inactive) and phase of regressing. B. V. Ilyinsky (1956) established that the hypercholesterolemia and decrease lecithin - cholesteric coefficient usually match a phase of morphological progressing of a disease and increase of clinical manifestations And. organ vessels. These data found confirmation in the subsequent researches, and diagnosis of phases A is possible now. on clinical manifestations and change of level of lipids and lipoproteins (in particular, it ß-lipoprotei-is new).
Many years And. can proceed asymptomatically, and its intravital diagnosis can be only accidental (at an angiography or the operations on vessels performed concerning other diseases). In individual options of a current And. its clinical manifestations in the form of bent to arterial spasms not always are early and corresponding to an initial stage of defeat of vessels or the period of «presclerosis». Sometimes the clinic of acute ischemic frustration in bodies is shown late — already against the background of considerable damage of arteries, a cut could be established by tool methods of a research earlier. This circumstance considerably raises a diagnostic role of tool researches (radiological, sfigmografiya, an ECG, etc.).
For the benefit of early diagnosis And., especially at mass routine maintenances, it is reasonable to consider the periods of disease as increase in the possibility and reliability of recognition And.
1. Preclinical (asymptomatic) period: clinical manifestations are absent, tool researches of vessels of pathology do not reveal. The maintenance of lipids in blood normal. The hypercholesterolemia or increase in fraction of beta lipoproteins during this period shall be regarded as the indicators of the increased risk of development of atherosclerosis proving need of overseeing by the corresponding persons and taking a step of individual prevention.
2. Latent clinical period. In this period of change of physical properties of arteries or their hemodynamic function come to light only by tool methods of a research. Other clinical signs are absent. Parallel identification of disturbances of lipidic exchange increases reliability of communication of the found vascular defeat with And.
3. The period of nonspecific clinical manifestations is characterized by symptoms of passing ischemic frustration in bodies (an ischemic stage according to A. L. Myasnikov), same, as at an idiopathic hypertensia or angioneuroses (with to-rymi and differential diagnosis is carried out), but combined with the signs of atherosclerotic defeat of vessels revealed instrumentalno or with steady characteristic changes of lipidic exchange. In this period heart attacks in bodies and a focal sclerosis (a fibrous stage according to A. L. Myasnikov) can already be observed which are also not strictly specific for And. (are observed at malignant arterial hypertension, an erythremia, vasculites), but And. is their most frequent reason.
4. Period of chronic arterial occlusion. It is characterized by obligatory ischemic frustration in zones of vascular defeat at a certain general exercise stress or a functional load of appropriate authorities: an angina of exertion (or its equivalents) at coronary And., the alternating lameness at occlusion of vessels of extremities, a belly toad at damage of mesenteric arteries etc. In this period fibrous changes in bodies are noted often, and diagnosis And. does not represent special difficulties since the differential diagnosis is carried out by hl. obr. only with much more rare the found vasculites.
Depending on localization And. (an aorta, arteries of heart, a brain, kidneys, mesenteries, the lower extremities) there are various clinical manifestations in each of the listed periods.
Atherosclerosis of coronal arteries of heart
At stage of latency coronary And. comes to light only regarding cases by methods of measurement of volume of a coronary blood-groove, napr, with the help radiotsirkulografiya (see) or on relative reduction of a gain of a coronary blood-groove in response to an exercise stress. For indirect assessment of the last it is usually used electrocardiography (see) with the dosed exercise stress on the stationary bicycle or the tredbena. About insufficiency of blood supply of certain sites of a myocardium at loading judge by disturbances of the processes of electric repolarization of a myocardium which are reflected the shift of a segment S — T and changes of a tooth of T in the corresponding assignments of an ECG. To initial clinical manifestations there correspond most often attacks stenocardias (see), periodic disturbances of a rhythm or conductivity in connection with ischemia of a myocardium, the centers of automatism or the carrying-out system of heart (see. Arrhythmias of heart , Heart block ). Since this period the clinic forms coronary heart disease (see) with clinical manifestations, characteristic of it (see. Myocardial infarction , Cardiosclerosis ). To specification of existence, localization and extent of atherosclerotic defeat of coronary arteries it is applied coronary angiography (see).
Atherosclerosis of an aorta
While according to section data atherosclerotic changes in an aorta are registered, as a rule, from second decade of life, initial clinical manifestations appear quite often only by sixth or seventh decade. However changes of physical properties of the affected aorta (the latent clinical period) occur much earlier. If to consider that the aorta is surprised more often than other arteries, these changes represent the greatest opportunities for early tool diagnosis And. at mass inspections.
Increase in rate of propagation of pulse wave in an aorta to 12 — 20 m/s is most indicative for atherosclerosis of an aorta, a cut of subjects it is more, than more on length of an aorta consolidation of its walls is expressed. At an idiopathic hypertensia without And. rate of propagation of pulse wave increases slightly that can be a differential diagnostic character. Changes of the sphygmogram are characteristic: bystry rise, the pointed top, abrupt descent with reduction of amplitude of additional waves on a catacrotism. Later growth of pulse pressure is noted (differences between systolic and diastolic pressure). X-ray inspection can be low-informative even during the expressed clinical manifestations, however more often already in stage of latency lengthening of an aortal arch is noted; the rentgenokimografiya reveals irregularity of amplitude of fluctuations of an aortal wall and deformation of teeth, «mute zones» on sites of a sharp sclerosis of walls and their calcifications. The focal calcification of an aortic arch which is difficult distinguished by means of the listed techniques can be found by special X-ray inspection using X-ray television (see. Television in medicine ).
During explicit clinical manifestations symptoms And. aortas are caused by localization of atherosclerotic process on length of a vessel.
Atherosclerosis of a chest aorta. Complaints of patients often are absent or are caused by the accompanying atherosclerotic damage of arteries of heart, brain. The aortalgiya — pressing or the thermalgias behind a breast irradiating in both hands, a neck, a back, an upper part of a stomach has Nek-ry specificity. Unlike angina pectoris, these pains have no accurate pristupoobrazny character, proceed for hours and even days, periodically weakening and amplifying, are quite often combined with paresthesias in hands.
The origin of an aortalgiya is connected with irritation of nerve terminations in a wall of the changed aorta or irritation of paraortalny neuroplexes at restretching of aortal walls. It is not excluded that regarding cases of pain are connected with disturbance of coronary circulation. During the narrowing by fibrous plaques of mouths of intercostal arteries dorsodynias and on perimeter of a thorax, similar to intercostal neuralgia can be noted.
In case of considerable expansion of an aortal arch emergence of the complicated swallowing in connection with a prelum of a gullet is possible. If hoarseness of a voice (a prelum of a recurrent nerve) or an anisocoria is noted, it is necessary to exclude aortic aneurysm (see). Seldom there are complaints characteristic of a so-called aortic arch syndrome (see. Takayasu syndrome ) — dizzinesses, orthostatic syncopes, a passing hemiparesis, sometimes epileptiform spasms at sharp turn of the head.
If the aortectasia is considerable, then at an objective research expansion of a zone of percussion obtusion at the level of II mezhreberye to the right from a breast on 1 — 3 cm comes to light. An important symptom is the so-called retrosternal pulsation caused by lengthening and high standing of an arch of the affected aorta. The pulsation of mezhreberiya to the right of a breast is very seldom observed. Percussion of heart can reveal the small shift of its borders and a nek-swarm strengthening of an apical beat at the expense of a moderate hypertrophy of a left ventricle; bigger expansion can be at the expense of dilatation of heart at simultaneous damage of coronal arteries with development of a cardiosclerosis.
At auscultation over an aorta systolic noise, an origin is quite often listened to-rogo it is connected with formation of pristenochny turbulences of blood in connection with rigidity and an insufficient aortectasia in the period of a systole, roughnesses of its inner surface in the locations of plaques, and regarding cases and with sclerous changes of semilunar valves of the aortal valve. Conditions for a systolic turbulence of blood appear also at a considerable aortectasia. Systolic noise usually amplifies if the patient raises hands and rejects the head back (Sirotinin's reception — Kukoverova), and also after an exercise stress. The second cordial tone over an aorta is often strengthened, accented, sometimes has a metal shade which appears at calcification of semilunar valves of the aortal valve.
In process of progressing And. on length of an aorta systolic and pulse arterial pressure grows; at defeat of an arch in places of an otkhozhdeniye of a brachiocephalic trunk and the left subclavial artery pressure and size of pulse on hands are not identical (on the party of defeat lower).
Clinical signs of heart failure appear only at the accompanying disturbances of a coronary blood-groove.
Atherosclerosis of a ventral aorta — the most frequent localization aortal And. At considerable atherosclerotic narrowing of mouths of a celiac trunk and other branches of a ventral aorta motility is consistently broken and secretory function went. - kish. a path that is shown by diskineziya of smooth muscle abdominal organs and disturbances of digestion of various degree. Insufficient blood supply of a pancreas can be shown not only disturbances of its excretory function, but also symptoms of the diabetes mellitus proceeding is usually good-quality (easy or moderate severity). At atherosclerotic occlusion of bifurcation of an aorta the clinical picture of a syndrome of Lerish forms (see. Lerisha syndrome ).
At a physical research the greatest information is given by a palpation of a ventral aorta if it is not interfered by often available meteorism. The palpated aorta makes an impression bent, its density is uneven; sometimes consolidation of an aorta is so considerable that it is taken for a tumor or aneurism. Regarding cases over an affected area of an aorta, especially at its expansion, systolic noise is listened.
To recognition And. a ventral aorta detection of the centers of calcification helps with its walls at a X-ray analysis. At early stages (during the latent clinical period) the rentgenokimografiya and an aortografiya are more informative, but these methods usually only in difficult differentsialno - diagnostic situations are applied.
And. a ventral aorta quite often leads to formation of aneurism with its possible stratification (see. stratifying ) or a gap (see. Aortic aneurysm ). A terrible complication is thrombosis of branches or a trunk of a ventral aorta. In the latter case blood clot is localized usually at the level of a branching of an aorta, corking one or both general ileal arteries. Clinical displays of thrombosis depend on speed of development, size of blood clot and a possibility of development of collateral circulation through outside ileal, hypogastric and internal chest arteries. Bystry development of thrombosis is shown by sharp one or both leg pains (according to the extent and localization of blood clot), their cold snap and falloff of pulse on femoral and more distal arteries; later gangrene of legs develops, disorders of function of pelvic bodies (disturbance of a mocheotdeleniye and defecation) join. Patients usually quickly perish if the early aortotomy with removal of blood clot is not made. At slow closing of a gleam of a ventral aorta and the general ileal arteries the clinical course of thrombosis is less terrible since collateral circulation develops, however weight of circulatory disturbances in the lower extremities and bodies of a small pelvis after all is considerable: weakness in legs progresses, muscles of legs atrophy, back pains and in legs disturb during the walking, defecation and a mocheotdeleniye are complicated, impotence develops. Recognition of thrombosis of a ventral aorta in such cases is based on signs of high arterial occlusion; at a palpation and by means of an oscillography considerable decrease in arterial pulse standing comes to light, the arterial pressure upon them is sharply reduced or is not defined by an auskultativny method at all. The diagnosis is specified by an aortografiya.
Atherosclerosis of mezenterialny arteries
Atherosclerosis of mezenterialny arteries is shown by the disturbances of functions of the digestive device similar to those at And. a ventral aorta since the basis of these clinical manifestations in both cases is made by ischemic frustration in digestive organs. However clinical symptomatology at And. mezenterialny arteries it is more expressed that is connected with spasms of the affected arteries while the clinic of the isolated defeat of a ventral aorta is defined by hl. obr. extent of organic narrowing of a gleam of mouths of its branches.
More often the upper mezenterialny artery is surprised, it is less than others supplied with an anastomosis with what, perhaps, decrease in secretory function of a stomach at elderly people is to some extent connected.
Complaints of patients to abdominal distention, locks, pressure sense in the epigastriums pricking abdominal pains with changeable localization (dyskinesia of separate intestinal loops), nausea, an eructation, etc. which can be isolated or variously combined and are usually noted in 2 — 4 hours after meal, reflect initial degrees of mezenterialny insufficiency. At the expressed atherosclerotic damage of arteries of a mesentery considerable disorders of motor function of intestines up to dynamic intestinal impassability, heavy digestive disturbances with secondary development of hypovitaminoses are possible and exhaustions.
Bright clinical manifestation And. mezenterialny arteries is belly toad (see). Its emergence always testifies to considerable extent of atherosclerotic process, but functional frustration of a tone of the affected arteries and in this stage of a disease play an essential role. The positive therapeutic effect of the spasmolytic drugs softening a current of a belly toad testifies to it.
From complications And. mezenterialny arteries the heaviest is thrombosis with development of heart attacks in an intestinal wall. Quickly developing thrombosis is shown by the accruing sharp diffuse abdominal pains (quite often in a combination or to the previous «wandering» pains on all stomach) with a tendency to localization in epigastric area. Pains are not stopped by drugs, at a palpation of a stomach change on intensity a little; during the first hours the stomach remains soft. Thrombosis of an upper mezenterialny artery is quite often shown by symptoms of high intestinal impassability, in particular a plentiful fecal vomit; at fibrinferment of the lower mezenterialny artery allocation with a stake of not changed blood is more often noted. Delay in purpose of heparin and fibrinolysin, as a rule, leads to development of peritonitis. Surgical intervention in such cases quite often is ineffective, and patients perish.
Atherosclerosis of a renal artery
Atherosclerosis of a renal artery on clinical symptomatology polimorfen. At localization of plaques in this vessel or at And. a ventral aorta in the field of an otkhozhdeniye of a renal artery there can be a sharp narrowing of a gleam of a renal artery up to closing of the separate branches departing from it. In the latter case in urine appear protein, erythrocytes, cylinders. At the same time the noticeable renal failure and increase in blood pressure does not come. However, if the mouth or a trunk of a renal artery are considerably narrowed, the maximal and minimal arterial pressure increases. At hemilesion the mochevyvedeniye can is still long remain normal, but further it is broken in connection with development of an arteriolosclerosis and arteriolonekroz and in the second kidney. While arteries of one kidney are not stenosed, the disease proceeds like a high-quality form of an idiopathic hypertensia, but with permanent changes in urine and permanent increase in arterial pressure. At sharp narrowing of arteries of both kidneys, a cut can develop at the same time or consistently, there comes the bilateral arteriolosclerosis, and the disease accepts a malignant current.
At a physical research of specific symptoms of a renal artery stenosis, as a rule, does not come to light; in certain cases over a renal artery systolic noise is listened. Special researches are applied to reliable diagnosis of a stenosis: an isotope renografiya, intravenous urography and an aortografiya with contrasting of renal arteries.
When And. a renal artery is complicated by her thrombosis, the heavy clinical picture which is characterized by a triad of symptoms sharply develops: strong long back pains, sometimes with the phenomena of shock, but without irradiation of pains, typical for a nephrolithiasis, in a bottom of a stomach and to the inguinal area; permanent increase in the maximal and minimal arterial pressure; emergence in urine of protein, erythrocytes and cylinders. Besides, the leukocytosis and acceleration of ROE can be observed.
Atherosclerosis of peripheral arteries
large arteries More are surprised, is more often in places of their branchings and bends. Subjective symptoms of defeat can be even absent long time during this period when recognition And. these arteries becomes possible according to their simple survey and a palpation. At damage of arteries of extremities, especially lower, clinical symptoms are shown more often and earlier, than at damage of the arteries supplying covers of the head, breast. It is caused by that at identical degree of an atherosclerotic stenosis (obliterating And.) the bringing arteries ischemic frustration are expressed in fabrics with the increased requirement more - in blood supply, napr, in muscles at an exercise stress.
One of early clinical manifestations And. arteries of extremities weakness and increased fatigue of the muscles eating from the affected artery is. Early there is also a feeling of a chill in extremities, paresthesias (feeling of the creeping goosebumps, numbness) and, at last, pains, usually for the first time appearing at height of an exercise stress join a bit later. For atherosclerotic damage of large arteries of legs it is typical so-called. the alternating lameness (see). In cold, dampness and other factors promoting spastic reactions of arteries (see. Vasomotor spasm ), pain arises more often.
At an objective research if the arteries available to survey and a palpation are surprised (e.g., temporal, beam), tortuosity of arteries (a symptom of «worm»), their considerable pulse shift, the uneven consolidation giving feeling of beads or «a goose neck» at a palpation is defined. At And. large arteries of legs pallor and a cold snap of the affected extremity are found, and in cases of severe defeat trophic frustration in its distal sites up to a gangrenosis come to light. Functional clinical trials (in particular, Goldflam's tests, Oppelya — see. Obliterating defeats of vessels of extremities ) reveal insufficiency of arterial inflow to a leg. Pulse on distal arteries is weakened or is not probed, arterial pressure in them is reduced.
Tool researches reveal disturbances of physical properties of the affected arteries of extremities at clinically stage of latency. Amplitude of sphygmograms, oscillograms and reogramm distal arteries decreases. The anacrotism of the sphygmogram is shortened on time, the top of the main wave is rounded quite often off, additional waves on a catacrotism smooth out. In process of progressing of process measurement of skin temperature reveals various extent of its decrease distalny the site of defeat; on plethysmograms of foot (or fingers of foot) decrease in volume pulse and reduction of rate of volume flow of a blood-groove is registered. Delay of peripheral speed of a blood-groove comes to light colourful or radio isotope by methods. Localization and extent of atherosclerotic narrowing most precisely are established by means of an angiography.
Atherosclerosis of arteries of a brain
Atherosclerosis of arteries of a brain — the frequent phenomenon at persons is more senior than 60 years. More often, earlier and in more expressed form it is observed at a combination of Ampere-second by an idiopathic hypertensia. At damage of large cerebral arteries or at a widespread hyalinosis of arterioles as it happens at an idiopathic hypertensia, memory, hl clearly decreases. obr. on recent events, intellectual working capacity decreases; patients quickly get tired, not can is long to focus attention on same, become emotionally labile, quite often complain of sleeplessness, headaches, dizziness, especially upon bystry transition from horizontal position to vertical. At expressed And. brain arteries the identity of the patient, his behavior considerably changes; various mental disorders can be observed. Among the reasons of symptomatic epilepsy of late age And. brain arteries one of the leading places belongs.
Local symptoms And. separate smaller arterial branches are: Cheyn's breath — Stokes (at damage of the arteries feeding a myelencephalon), an ataxy, dizziness (at insufficient blood supply of a cerebellum or vestibular mechanism), passing paralyzes, disturbances of the speech, sight, hearing, etc. In development of these disturbances can play a role and bent of muscles of walls of the arteries affected And., to the raised tonic contractions.
Especially heavy complications And. brain arteries are:
a) the hemorrhages (is more often from arteries of subcrustal nodes and the bridge) giving a terrible picture of suddenly coming loss of consciousness and development of a coma it is frequent from the death (see. Stroke );
b) more slowly and gradually developing fibrinferments (is more often than large arteries of bark) conducting to a necrosis of brain fabric with development in it of hems and cavities and which are followed by paralyzes and other disturbances, but without coma and a loss of consciousness (see. Thrombosis , vessels of a brain).
Mental disorders of that pla of other form and degree belong to frequent, though optional displays of atherosclerosis of brain arteries. The volume and borders of mental disorders in a crust, time are still insufficiently determined and are in many respects disputable. Is not subject, however, to doubt that mental disturbances at And. differ in a considerable clinical variety, i.e. are shown by the broad range of mental disorders.
Their following group is represented to the most reasonable: initial disturbances («pseudo-neurotic», «tserebrastenichesky», neurosis-like), various forms of atherosclerotic weak-mindedness, acute psychoses of exogenous and organic type and long psychoses (the difficult, endoformny, i.e. reminding circular psychosis or schizophrenia, affective, crazy and hallucinatory-dilision).
Allocation of initial mental disorders in special group is caused them by value for prevention and early treatment, an originality of their clinical manifestations and that circumstance that they can turn out so low-progreduated or even stable that they exhaust all mental changes at And. cerebral arteries.
Treat initial manifestations: 1) pseudo-neurotic states with characteristic complaints to headaches, noise in the head, dizziness, paresthesias of the person, frustration of a dream, increased fatigue and an exhaustion, decrease in working capacity at safety of the known compensatory opportunities, irritability, intolerance to noise, by a heat, etc., the suppressed mood, tearfulness, forgetfulness, etc.; 2) the states which are characterized, besides, by dominance of characterologic (psychopatholike) shifts in the form of a nek-ry point, the known deleting of traits of character earlier inherent to the patient; and first of all asthenic components of the personality — line of indecision, uncertainty in themselves, uneasiness while at manifestation of a disease at senile age personal changes can have the senilnopodobny shade reminding the initial stage of senile dementia owing to increase of rigidity and an egocentrism, callousness and avarice, indifference and emotional coarsening amplify; 3) at more progreduated course of mental disorders at And., except the listed symptoms, signs of nek-ry decrease in level of the personality and cerebration (an organic psychosyndrome, according to M. Bleyler), in particular decrease in mental activity, volume and clearness of perceptions, speed and productivity of cerebration, level of judgments and criticism are observed; rigidity and thoroughness of thinking, impoverishment of representations and concepts, easing of memory, especially selective reproduction and storing of new material, the lowered tearful and alarming mood, decrease (disinhibition is more rare) inclinations is noted. In an initial stage of mental changes at And. in response to the psychoinjuring situations reactive depressions of moderate weight rather often develop.
At a progreduated current the initial stage of mental changes without clear boundary passes into a condition of permanent, usually low-reversible impoverishment (disintegration) of all mental activity, into dementia. Quite often dementia develops sharply after disturbance of cerebral circulation (postapoplectic dementia).
At And. distinguish a number of forms (clinical types) dementias.
1. Lacunary (partial, dismnestichesky) — the most characteristic type of dementia at And. The uneven (partial) nature of mental changes, including mnestichesky frustration, safety of rough or partial orientation are inherent to it, skills of behavior and personal reactions (a so-called kernel of the personality) are generally kept. Slowness and a zatrudnennost of mental processes, the speech and motility, feeling of helplessness, decrease in level of cogitative activity, decrease in mental activity, dominance of the suppressed or alarming mood, tendency to fainthearted reactions are distinguished.
2. The anamnestic type of dementia is characterized by dominance of disturbances of memory, in particular existence of fixating amnesia (see), an anamnestic disorientation in the place and time and the replacing confabulations, i.e. development of a korsakovsky syndrome of various completeness and expressiveness (see. Korsakovsky syndrome ). This type of dementia at And. quite often arises after disturbances of cerebral circulation or acute psychoses and in these cases happens in a nek-swarm of degree reversible. At its development in old age, a thicket at a combination of atherosclerotic damage of a brain and a senile atrophy, the picture so-called hron, presbiofreniya can be observed (see. Senile dementia ).
3. At a so-called pseudoparalytic form of dementia of a dysmnesia, decrease in mental activity and delay of rate of mental processes are less expressed; carelessness and stupid euphoria, garrulity and an oblegchennost of associative processes up to moriapodobny foolish excitement prevail (see. Psychoorganic syndromes ). The criticism and level of judgments are sharply lowered. This type of dementia is observed usually at younger age, a thicket at the accompanying idiopathic hypertensia.
4. At the diffusion and widespread damage of brain arteries proceeding, as a rule, without strokes the so-called senilnopodobny form of dementia can develop, the clinical picture a cut reminds total dementia at senile dementia. This type of dementia is observed often at a combination And. brain arteries with a senile atrophy of a brain.
5. The form of dementia complicated by focal neurologic symptomatology arises postapoplectically or after the repeated, followed by the small centers of a softening disturbances of cerebral circulation. Her clinical picture is depending on localization, quantity and the size of the centers. At melkoochagovy defeat of extensive cortical area the syndrome of afatoaprakto-agnostic (psevdoaltsgeymerovsky) dementia — vascular option of the disease designated as develops Gakkebusha-Geyera-Geymanovicha syndrome (see).
All called options of a clinical picture of dementia at And. are seldom observed in pure form; it is more often about combinations in which this or that clinical type prevails.
Acute psychoses at And., the shown hl. obr. syndromes of exogenous type of reactions, differ at the same time a number of clinical features: 1) syndromes of the changed consciousness (delirious, amental, oneiric, etc.) often happen incomplete (rudimentary) and in the syndromal relation indistinctly outlined, usually designated as «conditions of confusion»; 2) short-term, tranzitorny psychotic states, in particular night conditions of confusion, as a rule, repeatedly repeating; 3) transitions of one syndrome to another are frequent (e.g., a delirium in a twilight state or an amentia, etc.); 4) acute and subacute psychoses with more difficult current, a cut it is not exhausted by syndromes of the dulled consciousness; there are also others the reversible, but not followed by disturbance consciousnesses — so-called transitional (intermediate, on Wicca) syndromes of affective, crazy or «organic» types. At the same time patterns of change of syndromes reflect the main tendency of disease process to a progreduated or regreduated current.
To to long psychoses, observed at And., belong hron, gallyutsinoza, most often verbal, are more rare visual, tactile or mixed. Polyvocal verbal gallyutsinoza of the menacing and condemning contents are followed by hallucinatory nonsense, and also affect of fear and alarm, usually become aggravated at night and accept scenic character, but the syndrome of hallucinosis, as a rule, does not become complicated. Long paranoiac psychoses, most often in the form of nonsense of jealousy at men, can meet at different stages of a current And. brain arteries, even in the presence of noticeable intellectual decrease. The interpretive nonsense happens in such cases poor, poorly developed and systematized.
From affective psychoses are observed preferential depressive, and with the broad range of options from obviously integrally painted («erased», «tearful», «complaining», «apathetic») to so-called endoformny, reminding endogenous (circular) depressions. The last cause quite often considerable differential and diagnostic difficulties, and their reference to mental disorders of vascular genesis remains doubtful.
At early stages of a disease depressive reactions are often observed.
Nek-ry authors described also rather rare, more difficult affective and crazy, hallucinatory-dilision (schizoformous) and other options of mental disorders at A.
Patogenez of mental disorders at And. differs in heterogeneity and complexity. Syndromes of the initial stage, condition of dementia and acute psychoses of exogenous type have more feedforward with cerebral vascular pathology, find a certain parallelism between aggravations And. and development of mental disorders that increases reliability of relationship of cause and effect between them. In other cases as, e.g., at hallucinatory paranoid, paranoiac and some depressive psychoses, such direct correlations between expressiveness and the course of somatic and mental changes usually are not observed, but the role of hereditary burdeness (first of all endogenous psychoses), premorbidal features of patients acts. Clinical, in particular katamnestichesky, observations showed that a considerable part of these psychoses shall be carried to endogenous diseases, the provoked and modified atherosclerotic process in vessels of a brain.
Diagnostic and differential and diagnostic difficulties concern hl. obr. these mental forms, especially as at prevalence And. brain arteries at late age of its combination to endogenous and other mental diseases are frequent. The differential diagnosis is based on the accounting of genealogical and anamnestic data, observations over patterns of a current, on the syndromal analysis and katamnestichesky observations over outcomes. Differential and diagnostic difficulties, solvable sometimes only on the basis of long observation, arise at differentiation of senilnopodobny forms of dementia from the mixed sosudistoatrofichesky diseases of senile age.
Atherosclerosis of pulmonary arteries
Atherosclerosis of pulmonary arteries meets seldom; as a rule, it is observed at the diseases proceeding with the increased blood pressure in vessels of lungs at some inborn heart diseases, at a mitral stenosis is more rare at mitral insufficiency, emphysema and a pneumosclerosis, a kyphoscoliosis, etc.) that indicates value of mechanical factors in its development.
Quickly enough atherosclerotic process develops in a pulmonary trunk at primary pulmonary hypertensia. Clinically it is shown by sharp diffusion cyanosis, respiratory insufficiency of diffusion type and symptoms of considerable pulmonary hypertensia (see. Ayersa syndrome ). Development And. a pulmonary trunk results in irreversibility of pulmonary hypertensia, against the background of a cut it arises, to a bystry invalidism and the death of patients. Therefore both pathogenetic, and, whenever possible, causal therapy of pulmonary hypertensia (including surgical correction) shall be early.
Radiodiagnosis of atherosclerosis
Radiodiagnosis of atherosclerosis aims to establish existence, prevalence and extent of atherosclerotic defeat of vessels. Radiological signs And. aortas are its expansion, lengthening, strengthening of intensity of its shadow and adjournment of lime in its walls. At raying, especially by means of X-ray television, it is possible to see a regional border from calcifications on a contour of a vessel. During a systole of a left ventricle all chest aorta is displaced to the left and up that demonstrates decrease in elasticity of its walls.
On a rentgenokimogramma and an elektrokimogramma deformation of teeth on a contour of an aorta, decrease in amplitude of a pulsation and its total absence in places of the greatest calcification is noted. Radiological more often defeat belly, than chest, aortas comes to light. The research of a ventral aorta is made preferential in a side projection.
Apply to specification of localization and extent of defeat aortografiya (see) and arteriography (see). Rather precursory symptom And. at an angiography reduction of extent of contrasting on edge of a vessel and existence of regional defects is. The symptom of uneven contrasting of an aorta is defined at an arrangement of atherosclerotic plaques on front or back walls.
At sharply expressed atherosclerotic process regional come to light big extent and it is central the located defects on the course of a vessel. The contour becomes broken, uneven, scalloped. Along with narrowing of a vessel sites of expansion of its gleam can be visible. In some cases at far come Ampere-second the stump of a vessel decides on the developed network of collateral circulation by occlusion of a vessel a conical or cylindrical shape. For definition of hemodynamic disturbances consider the speed of contrasting of the vessel located distalny places of defeat, and duration of a delay of a contrast agent in its proximal departments.
concerning life and working ability of patients the forecast substantially is defined by localization of process.
Development of single atherosclerotic plaques in large coronary arteries at a full intaktnost of all other vessels can lead to a heavy myocardial infarction from the death, and the disease can already lead to such outcome at the first clinical implication
of A. S of other party, common and extensive forms A are known. in many vessels, compatible to life for a long time even with preservation of working capacity. The important factor defining the forecast at And., the fitness of vascular reactions depending on a way of life of the patient, a ratio physical and cerebration and other reasons is. Acute disorders of regional blood circulation in a brain, heart and other bodies at the same localization and degree of manifestation And. are more probable at a hypodynamic way of life, at a combination of Ampere-second other diseases — a diabetes mellitus, the deforming spondylosis of cervical department (at And. brain vessels), a myxedema and especially with an idiopathic hypertensia since the last promotes progressing And., and also adversely influences a condition of the cardiovascular device.
As And. proceeds wavy, with change of phases of activation and regressing of process, not only its primary prevention (the prevention of the disease), but also secondary — the prevention of progressing is important And. and its complications.
Primary prevention at the heart of the shall be mass and assumes first of all reduction of influence of those pathogenic factors which accompany technical progress and an urbanization of the population.
Actions for environmental control, elimination of noise in the cities and at the enterprises, providing workers with conditions for rest out of territories of industrial facilities are in this respect represented important that is promoted, in particular, by shortening of working week. Significant role in primary prevention And. it is designed to play a dignity. - a gleam, work, edges shall begin promotion of the main measures of personal prevention in the contingents of the population of youthful age And., such as regular trainings by physical culture (with an explanation of pathogenic influence of a hypodynamia), observance of the correct work-rest schedule with a sufficient duration of a dream; carrying out days of rest in country conditions, sports, tourism; respect for moderation in food and variety of food (explanation of a pathogenic role of an excess kalorazh of food and adverse influence of obesity); exception of smoking.
To primary prevention And. also measures of the prevention and the timely treatment promoting development belong And. diseases of endocrine system — a hypothyroidism, a diabetes mellitus and other diseases of a metabolism, prevention of an idiopathic hypertensia. The persons who already have such diseases and also persons with hereditary burdeness on And. shall observe the listed measures of personal prevention especially carefully, more strictly limit contents in food of animal fats, kalorazh which shall make no more than 15% of all kalorazh of food. At identification of disturbances of lipidic exchange with the preventive purpose drugs of iodine and gipokholesterinemichesky means can be appointed. Tool researches of vessels for the purpose of early identification And. at such persons shall be carried out (to stage of latency) more often than in other groups of the population, and at earlier age (since 25 — 30 years).
Secondary prevention And. — the prevention of phases of its progressing — consists of obligatory inclusion of all measures of primary prevention and purpose of precautionary courses of treatment the special diyetetichesky mode, drugs of iodine and means of gipokholesterinemichesky, anticoagulating and vasodilating action.
A significant role in prevention and treatment And. belongs to a diet and physiotherapy exercises.
Treatment And. shall be complex, including drug, dietary, sanatorium treatment, physiotherapy exercises, and if necessary and surgical methods (see. Atherosclerosis, surgical treatment ).
Drug treatment is directed to normalization of lipidic exchange, processes of a blood coagulation and metabolism in vascular walls. In the presence of disturbances of nervous or endocrine regulation of exchange the drugs normalizing activity of regulatory systems are appointed: sedative or tonics, according to indications — Thyreoidinum (on 0,03 — 0,05 g 2 — 3 times a day), small to zy estrogen. The means promoting decrease in content of cholesterol in blood are at the same time appointed. Drugs of unsaturated fatty acids concern to them; lipotropic means (methionine, lipocainum and especially sincaline-chloride) and substances of gipokholesterinemichesky action: the beta sitosterol competitively interfering absorption of cholesterol from intestines; Atheromidum, Miscleronum, Clofibratum, a kata-lipid which are slowing down synthesis of endogenous cholesterol; holestiramin, stimulating excretion of cholesterol with bile acids. Dosing of these drugs and duration of their appointment are individualized depending on portability of drugs by patients and sizes of the reached therapeutic effect determined by dynamics of clinical symptoms and level of lipids of blood. Clinical effect, in particular in the form of reduction of cerebral ischemic frustration, drugs of iodine, and also Diosponinum (containing water-soluble steroid saponins) give. Are applied kaltsiyodin (Saiodinum), potassium iodide in the form of 3% of solution or 0,1% solution of pure iodine with potassium iodide (5 — 10 drops in milk 2 — 3 times a day) inside. Use of drugs of iodine is desirable courses on 3 — 5 weeks 2 — 3 times in a year. The solution of potassium iodide appointed in individual options from 1 chayn is preferable to easier selection of the dose which is not causing the phenomena of an iodism 3%. l. to 3 — 4 table. l. in day.
Gipokholesterinemichesky action is peculiar also to redoxon, nicotinic to - those, but indications to vitaminization at atherosclerosis are defined by generally their normalizing influence on metabolism of a vascular wall. With the medical purpose ascorbic to - that is used in high daily doses (to 1,0 — 1,5 g a day); doses another appointed at And. vitamins, in particular B2, B6, also shall exceed daily requirement. Dosing nicotinic to - you is limited to quite often bad portability of drug because of its vasoactive properties (the feeling of heat, sweat, a spotty dermahemia coming in connection with vasodilating effect).
Complex treatment And. includes also purpose of the drugs interfering development of regional circulatory disturbances, which hl. obr. also define the forecast of a disease: e.g., koronarolitik at coronary heart disease, the means expanding brain arteries at their defeat, etc. and also anticoagulants at threat of trombotichesky complications.
Clinical nutrition. A number of medical tables which cornerstone is is offered: a) restriction for 10 — 15% of the general caloric content of food (for persons with an excess or normal weight); b) reduction in a diet of animal fats and products rich with cholesterol (brains, egg yolk, caviar, fat grades of meat and fish), and also vitamin D, sodium chloride and extractives (broths, fish soup); c) inclusion in a diet in rather large numbers of the products rich with lipotropic substances (cottage cheese, well soaked herring, a cod, porridge, etc.), vegetable oils (sunflower, corn, linen, cotton), the vegetables, fruit rich with a cellulose. Severity of a diet depends on bigger or smaller expressiveness of disbolism of the patient. At the excess weight purpose of fasting days is reasonable (apple, kefiric, cottage cheese, kompotny, etc.). The day diet shall contain 30 — 40 g of complete proteins (meat, fish, low-fat dairy products, ovalbumin).
Physiotherapy exercises. Systematic muscle performance is one of prophylactics A.; it levels a disproportion between a hypodynamia and psychological tension. In the presence And. physical exercises are applied with the medical purpose or as a component of rehabilitation actions after a myocardial infarction, a stroke, after operative measures on heart and vessels. Except for the acute period of regional circulatory disturbances, contraindications for purpose of physiotherapy exercises at And. no.
The Kliniko-fiziologichesky basis of action of physical exercises at And. their ability to stimulate energy balance towards activation of enzymic oxidation and lipidic exchange, and also an opportunity by means of a physical training to compensate the broken functions, to increase the level of functioning of cardiovascular system, to reduce the phenomena of a hypoxia of the struck bodies and fabrics serves. The physical dosed training slows down blood coagulation and increases function of anticoagulative mechanisms, actively influences development of collateral circulation in a myocardium, promotes adaptation of coronary circulation to exchange requirements of a myocardium, reduces the level of cholesterol in blood.
At stage of latency And. morning hygienic exercises, walking are recommended; on the weekend and during issue — tourism, sports, rowing, skiing, pipits, physical work on air and so forth. During the expressed clinical manifestations And. first of all the remedial gymnastics and walks on foot are appointed. In the procedure of remedial gymnastics it is reasonable to use breathing exercises, exercises with the dosed effort of muscles of hands and legs for improvement of peripheric circulation. At the same time a certain selection of physical exercises provides not only fortifying action on an organism of the patient, but also a special training of the struck body depending on preferential localization of atherosclerotic process in heart, a brain, at atherosclerotic occlusions of peripheral arteries.
Considering danger of an excessive exercise stress in the period of atherosclerotic occlusion of arteries (an angina of exertion, the alternating lameness), it is necessary to observe moderation and gradualness in increase in an exercise stress according to clinical manifestations and a current And.
Clinical observations and special physiological and biochemical researches (a teleelectrocardiography, a ballistokardiografiya, a reovazografiya, tests with an exercise stress, researches of lipid fractions and lipoproteins of blood, etc.) show that physiotherapy exercises, improving adaptation processes in an organism of the patient A., promotes increase in its physical effeciency and more bystry labor and social rehabilitation.
Indications to sanatorium treatment — see. Sanatorium selection .
Treatment of mental disorders at And. shall be combined, i.e., except use of psychotropic drugs, the great value keeps the treatment of the basic vascular disease directed to improvement of food and blood supply of a brain, and also to elimination of heart failure. Such therapy is especially important at the acute psychoses which are followed by disturbance of consciousness. In initial stages the organization of the correct mode of work, life and rest, food, and also rational psychotherapy matter. Depending on a mental condition of patients tranquilizers, neuroleptics and antidepressants according to the standard indications in psychiatry find application. However psychotropic drugs can cause a decompensation of vascular process therefore purposes of the most strong drugs avoid and select drugs gradually and carefully; it is necessary to avoid the high dosages applied at other mental diseases.
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A. M. Vikhert; V. P. Zhmurkin, B. V. Ilyinsky, L. A. Myasnikov (wedge., to lay down., prof.); A. I. Zhuravleva (to lay down. physical.), Κ. X. Rabkin (rents.); Yu. E. Rakhalsky, E. Ya. Shternberg (psikhiat.).