CORONARY HEART DISEASE (grech, ischo to detain, stop + haima a wound; synonym coronary disease) — the form of pathology of heart including group of diseases and morbid conditions which main causative factor is the atherosclerosis of coronal arteries causing under certain conditions discrepancy between the need of a myocardium for blood supply and possible size of inflow of blood on the affected artery. A number of researchers carries to And. page also exceptional cases of ischemia and a necrosis of the site of a myocardium arising on unknown so far to the reasons at not changed coronal arteries of heart.
It agrees the «Statistical classification of diseases, injuries and causes of death» accepted in the USSR based on the recommended WHO of the international classification of diseases (1965), coronary heart disease is considered as nozol, the form also combines 5 main options, or forms, its manifestations which are allocated in independent subheadings: 1) acute myocardial infarction (lasting current up to 8 weeks); 2) other acute and subacute forms I. the pages including ischemia of a myocardium, its melkoochagovy necroses, a so-called preinfarctive syndrome, «an intermediate coronary syndrome»; 3) angina pectoris (stenocardia); 4) asymptomatic And. page (not having a wedge, manifestations, but distinguished by means of an electrocardiography); 5) chronic And. page, including forms I. the pages designated as acute, but the lasting more than 8 weeks, and also recognizable atherosclerosis of coronal arteries of heart and the cardiosclerosis caused by it (including postinfarction).
And. the page is one of the most important reasons of mortality, temporary and persistent disability of the population in the developed countries of the world. So, in the USA, according to official data for 1971, 1 927 542 persons, and on a share died of all reasons And. the page was necessary 674 292, i.e. apprx. x / z all cases of death. The same year among the busy population in the USA loss is noted from And. page apprx. 9 million days of working capacity.
The term «coronary heart disease» for the first time appeared in domestic literature in the late fifties — the beginning of the 60th. Implementation of this term in a wedge, practice caused discussions since not all clinical physicians saw advantages of its use in comparison with the term «atherosclerosis of coronal (coronary) arteries of heart» used in our country and considered these terms equivalent. Supporters of implementation of the new term noted that it reflects pathogenetic essence of a disease (ischemia of a myocardium) more accurately. The concept «coronary heart disease» is not identical to the concept «coronary insufficiency». Except atherosclerosis of coronary arteries, can lead many other diseases to emergence of insufficiency of blood supply of a myocardium and patol, states: inflammatory defeats of coronary arteries (coronaritisis), a syphilitic mesaortitis at distribution patol, process on mouths of coronary arteries, embolisms of coronary arteries trombotichesky masses, some heart diseases, anomalies of development of coronal arteries, etc. (see. Coronary insufficiency ). However these options of coronary insufficiency do not correspond to the concept «coronary heart disease» and are considered as secondary within corresponding nozol, forms (rheumatism, syphilis, etc.).
Etiology and pathogeny
Aetiology and pathogeny of all forms I. pages connect with development of atherosclerosis (coronary) arteries which is accepted by most of researchers or as etiol, a factor or as a necessary condition of its emergence. From a myocardial infarction atherosclerosis of coronal arteries of heart is practically found in the dead always; with development of a method coronary angiography (see) — uses of additional projections — and improvement of interpretation of a koronarografichesky picture the frequency of detection of atherosclerosis of coronary arteries at patients with stenocardia also approaches 100%. In rare instances, especially at the patients of young age who had a macrofocal myocardial infarction, neither the pathoanatomical research, nor data of coronary angiography reveal atherosclerosis or other organic lesions of coronary arteries of heart. Many authors carry similar cases to And. page. However there is an opinion that it is about some other, not deciphered yet, but independent nozol, the form connected with damage of small arteries of heart in whom atherosclerosis does not develop, with disturbance of microcirculation and development of the ascending thrombosis or of a spasm not region atherosclerosis of an artery in combination with disturbances in coagulant and anticoagulative systems of blood.
Great value in emergence, development and formation a wedge, manifestations of PI. the page is given to so-called risk factors. The research conducted in Fremingem (USA) on the representative contingent of the population for a long time and also some other works showed that risk factors for And. pages are age, belonging to a male, the increased maintenance of lipids in blood serum, the arterial hypertension, smoking of cigarettes, a diabetes mellitus, obesity insufficient physical. activity, some features of the personality and behavior, genetic predisposition, the increased contents uric to - you in blood and insufficient rigidity of drinking water. Existence of one of these factors and especially their combination considerably increases individual danger of developing of atherosclerosis in general, atherosclerosis of coronal arteries and, respectively, And. the page, though does not do it fatally inevitable. Role of some risk factors in emergence And. by page it is in a varying degree deciphered (e.g., atherosclerosis progresses with age and meets at some forms of a lipidemia more often, and also at arterial hypertension), value of others is a subject of intensive researches.
It is established that the expressed atherosclerosis of coronary arteries of heart and even their occlusion come to light at persons without wedge, manifestations And. page. Quite often noted discrepancy between extent of atherosclerotic defeat of coronary arteries and weight of a current And. the page indicates a role of additional conditions of developing of ischemia of a myocardium, a part of which can be connected with features of a course of the atherosclerosis. One of such conditions — the bystry rate of development of coronary atherosclerosis advancing formation of the developed system of collaterals capable to provide the increased need of a myocardium for blood supply at physical. and emotional loadings. With introduction to a wedge, practice of the selection coronary angiography also pathogenic role of a spasm of coronal arteries, long time which was considered doubtful is established. The spasm cannot really arise in rigid owing to massive atherosclerosis and quite often calciphied arteries, however in the arteries affected with atherosclerosis not throughout and in the presence of initial displays of atherosclerosis it is observed quite often. In cases of the heavy stenosing atherosclerosis of the main arteries the spasm of the collateral branch which is a little changed by atherosclerosis can matter, apparently. The possibility of a spasm of intact coronary arteries remains obscure.
The role of thrombosis of coronary arteries is discussed by hl. obr. in an origin of one of forms I. page — a myocardial infarction. Usually blood clot is formed in the field of an arrangement of an atherosclerotic plaque (especially at an ulceration of a plaque or a hemorrhage in its basis). There is an opinion that at And. the page of fibrinferments can arise owing to disturbance of microcirculation and metabolism and in walls of small vessels. Probably the coronary insufficiency caused by atherosclerosis of larger arteries can be the cause of these disturbances. Developing of thrombosis in the struck coronary artery is promoted by disturbance of coagulant and anticoagulative properties of blood inherent in atherosclerosis as in an organism in general, and locally, in the field of an arrangement of a plaque.
The pathological anatomy, clinical manifestations, the forecast, treatment and prevention
Pathological anatomy, clinical manifestations, the forecast, treatment and prevention are defined by specific forms of manifestations And. page (see. Myocardial infarction , Cardiosclerosis , Stenocardia ). Between such forms I. the page as a myocardial infarction and stenocardia, exist intermediate forms, to the Crimea carry a melkoochagovy myocardial infarction and focal dystrophy of a myocardium. Besides, stenocardia is divided into stenocardia of rest, an angina of exertion and Printsmetal's stenocardia (the stenocardia caused by a spasm of coronary vessels; it is characterized by raising of a segment of ST on an ECG, passes independently at change of position of the patient from horizontal in vertical); and a myocardial infarction — on melkoochagovy and macrofocal (tab.).
the Diagnosis is made on the basis of recognition of one of forms I. page, detection of atherosclerosis of coronary arteries of heart and an exception of others patol, states and diseases which can cause development of coronary insufficiency (see).
Because the term «coronary heart disease» appeared in domestic medicine relatively recently, difficulties in a formulation of the diagnosis are not overcome yet And. there is no page Since a consensus about whether it is necessary to carry to And. those cases of a myocardial infarction in which any pathology of coronary arteries does not manage to reveal P.E. Lukomsky (1974) suggested to supplement with page the formulation of the diagnosis And. page the instruction on atherosclerosis of coronary arteries if it obviously is the reason of coronary insufficiency or its effects (e.g., «And. page, transmural myocardial infarction of a back wall of a left ventricle of heart, atherosclerosis of an aorta and coronary arteries of heart»). In the same exclusively exceptional cases when the doctor is convinced that atherosclerosis of coronary arteries at the patient is absent and at the same time coronary insufficiency or its effects are not result any other patol, the states which are not relating to And. the page (a coronaritisis, a tumor of a coronary artery, an injury etc.), the diagnosis is limited to the instruction on And. page and its form, but without mentioning of atherosclerosis of coronal arteries (e.g., «the Deputy page, a transmural heart attack of a front wall of a left ventricle of heart»). At the same time it is not necessary to enter into the diagnosis the instruction on And. page if coronary insufficiency, the myocardial infarction or a cardiosclerosis are caused not by atherosclerosis, but other known reasons. In spite of the fact that the specified recommendations about creation of the diagnosis at And. pages are not indisputable, they are accepted to lay down in the majority. institutions of the USSR.
Orientation in creation of the diagnosis And. the page on headings and subheadings in the accepted statistical classification of diseases does not exclude use of the terms traditional for domestic medicine (e.g., «stenocardia of rest», «a diffusion cardiosclerosis»), and also terms which have no equivalents in the available headings of classification. Some domestic authors, e.g. V. G. Popov (1972), allocate a peculiar option of a current And. the page — hron, coronary insufficiency, edges sometimes meets in a wedge, practice, but cannot be formally carried to one of subheadings of the official nomenclature. This option is characterized repeated long (30 min. and more) and often very intensive retrosternal pains which are quite often arising daily or even several times a day. Pains, as a rule, have localization, typical for stenocardia, and irradiation, but arise without obvious dependence on any external factors and are not stopped by nitroglycerine. On an ECG at the same time only unstable changes of a final part of a ventricular complex periodically are registered: nek-paradise a depression of a segment of ST, flattening or inversion of a tooth of T in these or those assignments; at the same time changes of laboratory indicators characteristic of a myocardial infarction, no. The described picture can be observed within several weeks, months and even years and most often comes to an end with development of a typical myocardial infarction. Are not included in the official nomenclature and such forms I. pages which are shown only by disturbances of a heart rhythm (including in connection with disturbances of conductivity). Nevertheless at a formulation of the diagnosis all these forms can and shall be mentioned after ascertaining of existence And. pages are also carried to the corresponding headings of the nomenclature, e.g.: «Chronic And. page, hron, coronary insufficiency» or «Chronic And. page, an arhythmic form» (with the indication of a specific type of disturbance of a rhythm) etc.
The approved WHO «Nomenclature of diseases, injuries and causes of death» is regularly reconsidered by committee of experts whose part also the Soviet researchers are; it is not excluded that a number of the subheadings accepted by domestic clinical physicians And. the page will be included in this nomenclature at the subsequent reviews.
Table. Differential and diagnostic characteristic of various forms of coronary heart disease
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