TOPIC1

Chronic forms of coronary heart disease (CHD)

1. A 47-year-old man complains of compressive pain behind the sternum during
accelerated walking, climbing 3 floor. He has been sick for 6 months.
Clinician-observed: Height - 172 cm, weight - 98 kg.
Lungs: vesicular breathing.
The borders of the heart are not shifted, the tones are muffled, the rhythm is correct,
heart rate = PS = 72 bpms., BP = 135/80 mm Hg.
The liver is not palpable, no swelling of the legs.
ECG is without changes. In the blood:
Red blood cells - 4.5*10¹², white blood cells - 7.0*10⁹, ESR - 5 mm / h.

 Formulate a clinical diagnosis.

IHD: First established angina pectoris- Class I experience angina with strenuous or protracted
physical activity

 Make a survey plan with rationale.

In chronic stable angina, typical history and presence of risk factors are the most important
information for diagnosis. The physical examination is usually not helpful but may provide
evidence of left ventricular systolic or diastolic dysfunction (S3 or S4, respectively). During an
attack of angina, patients tend to be still and may appear pale. The ECG is normal in more than
half of patients with coronary atherosclerosis, but there may be evidence of prior myocardial
infarction or ischemia (e.g., ST depression).
The three most important determinants of prognosis in patients with chronic stable angina are
age, number of diseased coronary arteries, and left ventricular function.
An exercise treadmill test can diagnose CAD by the development of ECG changes with
exercise. In addition, symptoms during exercise, blood pressure response, and duration of
exercise are all important in determining the post-test probability of CAD and whether the
patient needs further evaluation.
The treadmill test can be enhanced by assessing left ventricular wall motion (with
echocardiography) or myocardial perfusion (with nuclear imaging). Pharmacologic stress testing
can be used in patients who are unable to exercise.
The recent advent of 64-slice computed tomography (CT) scanners has enabled noninvasive
coronary angiography. Patients are given an intravenous bolus of contrast dye, and then the
coronary arteries are imaged. The usefulness of this test remains to be determined, but there are
promising data, especially in excluding CAD in low-risk patients.
CT angiography has several limitations, including significant radiation exposure, exposure to
contrast dye, the need to be in sinus rhythm, and an ability to tolerate relative bradycardia.
Direct coronary angiography remains the gold standard for diagnosing CAD.
This test, which involves direct injection of contrast dye into the coronary arteries, delineates the
location and severity of obstructive coronary disease. As such, angiography is a necessary
prerequisite for coronary revascularization through either percutaneous intervention or coronary
artery bypass surgery.
Left ventriculography, generally performed immediately before or after coronary angiography,
provides important information regarding intracardiac pressures and left ventricular function.
Clinically assessing the functional importance of intermediate lesions (lesions that appear to
obstruct 40% to 60% of the coronary lumen) may be difficult using coronary angiography alone.
This limitation can be partially overcome by using intracoronary ultrasound or by measuring
coronary flow velocity or intracoronary pressure changes during maximal hyperemia.
 Define treatment tactics.
Nonpharmacologic Interventions Controlling risk factors for atherosclerosis is crucial. In
particular, patients should be advised on the need to lower the intake of cholesterol and saturated
fat in their diets, the importance of weight loss if obese, and the need to avoid tobacco. A regular
exercise program should be prescribed for all patients in whom it is feasible. An exercise stress
test can be used to determine safe levels of activity. Transmyocardial revascularization, enhanced
external counterpulsation, spinal cord stimulation, and sympathectomy are occasionally used in
patients who have refractory angina despite optimal medical treatment. Pharmacologic
Interventions Pharmacologic therapy for angina was traditionally directed at relieving symptoms.
More recently, medications have been classifi ed based on their effect on survival .
Medications that improve survival and decrease cardiovascular events in patients with CAD
include aspirin, hydroxymethyl glutaryl–coenzyme A (HMG-CoA) reductase inhibitors
(“statins”), and angiotensin-converting enzyme inhibitors.
In patients with prior myocardial infarction or left ventricular dysfunction, β-blockers also
reduce mortality. Medications that treat symptoms without improving survival include nitrates
and calcium channel blockers. The use of calcium channel blockers, with the exception of
amlodipine and felodipine, should be avoided in patients with left ventricular dysfunction.
Low-density lipoprotein (LDL) cholesterol levels should be aggressively lowered, even in
patients with ostensibly normal LDL levels, through the use of diet and statins. Recent guidelines
suggest that LDL cholesterol should be less than 70 mg/dL in patients with CAD. Blood pressure
should be closely monitored, with optimum levels below 140/90 mm Hg.
In diabetic patients, optimum levels are even lower, with the goal of diastolic blood pressures at
80 mm Hg or less. Patients must be strongly encouraged to quit smoking and offered
pharmacologic aids (e.g., nicotine patches, bupropion, varenicline) or support group help as
needed. Antioxidant vitamins have not been shown to be beneficial.
2. A 55-year-old woman complains of burning pain behind the sternum, which appears
while walking up to 200 meters, climbing 1 floor; interruptions in the work of the
heart. Considers herself sick since 2017, when she suffered from AMI. The same year
coronary angiography was performed (stenosis 85% in the right coronary artery was
revealed) and PCA stenting was performed.
No menstruation for 5 years.
Constantly takes beta-blockers, aspirin, when she is in pain - nitroglycerin.
Clinicianobserved: Lungs: vesicular breathing. The borders of the heart are extended
to the left +1 cm, tones are muffled, single extrasystoles, heart rate = 86 bpms, PS =
82 per minute, blood pressure = 155/85 mm Hg. The legs are pasty. Blood: White
blood cells - 5.6*10⁹, ESR - 12 mm / h. ECG - ventricular extrasystoles, left
ventricular hypertrophy.
 Specify the most likely diagnosis.
AORTIC STENOSIS
 What is your treatment tactic?
Although careful physical examination and electrocardiography can detect left
ventricular hypertrophy in moderate or severe obstruction, precise quantifi cation of
aortic stenosis requires echocardiography for anatomic assessment and evaluation of
left ventricular wall thickness, chamber size, and contractile performance.
Simultaneous Doppler studies should be performed to measure left ventricular outfl
ow velocity, mean transvalvular pressure gradient, and valve area. Invasive
assessment in the cardiac catheterization laboratory may be recommended in
symptomatic patients when noninvasive tests are inconclusive or there is discrepancy
between clinical and echocardiographic fi ndings.