Chapter 3. Cardiovascular diseases

3.1. Ischemic heart disease

Formulating a diagnosis

Components of the diagnosis: clinical form; complications; underlying health condition

Coronary artery disease (CAD) is a disease associated with reversible decrease or complete cessation of the blood supply to the myocardium due to organic (irreversible) and functional (transient) changes in the coronary arteries.

The main pathogenetic factor of the organic damage to the coronary arteries is atherosclerosis that causes more than 95% of CAD cases. Functional changes include spasm and intravascular thrombosis of the intact coronary arteries.

CAD takes one of the leading positions all over the world because of its socio-economic consequences and prevalence. In the Russian Federation, CAD is the most common reason for visiting medical institutions among adults with cardiovascular diseases (CVD) — 28% of cases. More than half of deaths from CVD are attributable to CAD.

Quick tips

The term “CAD” includes in it chronic (stable) and acute (unstable) con­ditions. Stable (chronic) CAD is characterized by reversible episodes of ischemia; as a rule, it manifests itself as a transient chest pain. Acute coronary syndrome (ACS ) is a group of clinical signs reflecting the CAD exacerbation period and allowing to suspect acute myocardial infarction or unstable angina.

Clinical types of stable coronary artery disease

In recommendations of the Russian Society of Cardiology and the affi­liated scientific medical communities of the Russian Federation, the clinical classification of stable CAD is defined in the guidelines in this way.

Clinical classification of stable CAD (RSC/RNAS/RNSAT/RACVS, 2020).

1. Angina:

1.1 stable exertional angina (with indication of the functional class according to the Canadian Cardiovascular Society grading);

1.2. vasospastic angina;

1.3. microvascular angina.

2. Post-myocardial infarction cardiac fibrosis.
3. Silent myocardial ischemia.
4. Ischemic cardiomyopathy.

The recommendations of the European Society of Cardiology on the treatment of stable forms of CAD introduced the concept of chronic coronary syndromes. Six clinical scenarios have been identified, which are different evolutionary phases of CAD and associated with different cardiovascular complication risks (CVC).

Chronic coronary syndromes (ESC, 2019)

1. Patients with stable exertional angina and/or dyspnea.
2. Patients with suspected symptoms of vasospastic or microvascular angina.
3. Patients with new onset of heart failure, left ventricular dysfunction.
4. Patients (symptomatic and asymptomatic) less than one year after the initial diagnosis of CAD, ACS and/or revascularization.
5. Patients (symptomatic and asymptomatic) more than one year after the initial diagnosis of CAD, ACS and/or revascularization.
6. Asymptomatic patients with CAD identified at screening.

The RSC/RNAS/RNSAT/RACVS, 2020 classification is the generally accepted classification of the stable CAD approved by the Ministry of Health of the Russian Federation.

Complications

CAD may have a long chronic course, which may exacerbate at any given time due to the development of critical cardiovascular syndromes requiring emergency hospitalization. CAD complications:

• chronic heart failure;
• rhythm and conduction disorders;
• syncope;
• pulmonary edema;
• cardiogenic shock;
• pulmonary embolism;
• sudden cardiac death.

Underlying diseases and comorbidities

The underlying disease affecting the CAD course: hypertension, diabetes mellitus, obesity, dyslipidemia, anemia, thyrotoxicosis, polycythemia vera.

Comorbidities affecting drug therapy selection: aortic stenosis, hypertrophic cardiomyopathy, cerebrovascular disease, lower extremity arterial insufficiency, bronchial asthma, COPD, prostate adenoma, viral hepatitis, alcoholic liver disease, chronic kidney disease.

Examples of diagnoses

DS: CAD: Stable angina, functional class II. Hypertension stage III, uncontrolled arterial hypertension, very high risk. Target BP <130/<80 mm Hg.

DS: CAD: Crescendo angina. Type IIb dyslipidemia. Grade 1 obesity.

DS: CAD: Ischemic cardiomyopathy. HF with reduced LVEF (38%), stage IIb, functional class III (NYHA). Type 2 diabetes mellitus.

DS: CAD: Post-myocardial infarction fibrosis. Permanent atrial fibrillation. Hypertension stage III, uncontrolled arterial hypertension, very high risk. Target BP <130/<80 mm Hg.

Diagnosis verification

Diagnosis of CAD is based on a patient interview, a patient history, physical examination, instrumental and laboratory tests. The presence of the following criteria is required for the diagnosis of CAD:

• clinical symptoms equivalent to myocardial ischemia;
• instrumental, laboratory signs of ischemic myocardial damage;
• detection of coronary artery changes;
• the presence of risk factors for cardiovascular complications.

Quick tips

The purpose of diagnostics in stable CAD is to determine the risk of CVC by the following main indicators: