Riziku stratification. Stratification of heart disease in ailments for stable coronary disease of the heart (oglyad) stratification of heart disease

Arterial hypertension. Viznachennya. Classification. Riziku stratification.

Arterial hypertension - syndrome of admission arterial vise more than 140/90 mm Hg Arterial hypertension can be diagnosed as a part of hypertensive ailments, as well as in symptomatic hypertension.

KLASIFIKATSIYA arterial hypertension photographed on Rivni AT.

Isolated systolic arterial hypertension 140 and more; Mensh 90

stratification of risik

Riziku factories: Separation of organ-targets, Level of systolic and diastolic AT, Вік older than 55 years in women and 65 years in women, Kurinnya, Dyslipidemia (concentration of zeal cholesterol is more than 6.5 mmol / L, or LIL) LPVSH less than 1.0 mmol / l in cholovikiv and less than 1.2 mmol / l in females) *

* Donation of extravagant cholesterol and LPNSH to be used for stratification of rhizic disorders in case of arterial hypertension.

Early heart-shaped sickness among close relatives (younger than 55 years in choloviks and 65 years in women)

abdominal obesity(The circumference of the waist is 102 cm and is larger for choloviks, 88 cm and is larger for women)

Concentration of C-reactive blood cell 1 mg / dL or more **

Separating organs-targets:

Hіpertrophy of the lіvnogo slung (EKG: index of Sokolov-Layon more than 38 mm, Cornelian index greater than 2440 mm / ms; EHKG: index of the mass of myocardium of the lіvnuyu slungka dorіvnyu 125g / m2 and more than / m2)

Ultrasound signs of arterial stiffness or the presence of atherosclerotic plaque

A small increase in the concentration of creatine in the blood (115-133 μmol / L y), Microalbuminuria.

association CLINIC STANI:

Diabetes mellitus: glucose from venous plasma at more than 7.0 mmol / l or more, Cerebrovascular ailment: ischemic stroke, hemorrhagic stroke, less cerebral blood circulation

Heart disease: myocardial infarction, angina pectoris, chronic heart failure

Disease of nirok: diabetic nephropathy, nirkova lack(The concentration of creatine in the blood is more than 133 μmol / l in choloviks, more than 124 μmol / l in females), proteinuria (more than 300 mg / dob)

Involvement of peripheral arteries

Retinopathy is violated: hemorrhage abnormally exudate, swelling of the nipple of the external nerve.

2. Hypertensive ailment: etiology, pathogenesis, factors of rhizic,.

Hypertensive ailments are chronically associated with ailments, the main manifestation of which is arterial hypertension syndrome, not associated with the manifestation of pathological processes,

Prior to the factors of the risk, it is necessary to admit overwhelmingly kitchen salt, Obesity, adjustment of the activity of renin-angiotensive-aldosterone nice systems... mill yak іnsulііresistance - mill, at yak

the deterioration of the sensitivity of the fabric to insulin is meant. As a result, compensatory

to move products to the insulin and yogo in the place of the blood. I will call this phenomenon hyperinsulism. , Genetic schism, endothelial dysfunction (how to turn around like endothelial and nitrogen oxide), low vagi in case of population and the nature of intrauterine malnutrition, neurovascular anomalies.

The main cause of hypertension- Change of education for other vessels. Basically pathogenesis: Zbіlshennya obsyagu chilinny heart wikidu that support of the peripheral vessel channel. There is a deterioration in the regulation of the tone of peripheral vessels by the visual centers of the brain (hypothalamus and dovgastimmozcom). Vinikє spasm of arterioles on the periphery, including Ch. Nirkovikh, scho formation of dyskinetic and dyscirculatory syndromes. The secretion of neurohormones of the renin-angiotensin-aldosterone system is improving. Aldosterone, which takes care of the fate of the mineral exchange, wicks to catch water and sodium in the riverbed. Inert stinks of the vertebral column sound, and the sound of the backward rim of the peripheral support of the vertebral body and to rob the arterial hypertension with a nonvortex.

Riziku factories: Psychomotional stress, increased implantation of salt, decline, diabet, Atherosclerosis, obesity, ailments nirok, klimax, vik, alcoholism, kurinnya, hypodynamia.

3 Clinical picture and diagnostic dosage for arterial hypertension.

Stage I (easy)- periodically arterial vise (diastolic vise - over 95 mm Hg) with possible normalization of hypertension without lykarskogo lykuvannya... Before the hour of the crisis of ailment, skarzhitsya on the head beel, zamorochennya, seeing the noise in the head. The crisis can be seen clearly in our visions. Objectively, it can be seen that only sore arterioles, enlarged venules and hemorrhages on the face-to-face day without any organ pathology. Hypertrophy of the myocardium of the lilac slug is mute.

Stage II ( average gravity) - stable adjustment of the arterial vise (diastolic vise - from 105 to 114 mm Hg. Art.). The crisis is developing on the smallest of the arterial vise, if the crisis is allowed, the vise does not normalize. Visual changes in the bottom, signs of hypertrophy of the myocardium of the louse, the steps of which can be assessed in case of radiological and echocardiographic indications.

III stage (important)- stable adjustment of the arterial vise (diastolic vise-ponad 115 mm Hg. Art.). A crisis can also develop on the back of an advanced arterial grip, as it does not normalize if the crisis is allowed. Day-to-day fluctuations in the second stage of a larger turn, develop arterio- and arteriolosclerosis, before the hypertrophy of the lingering shlunochka, cardiosclerosis occurs. There are secondary changes in the internal organs.

Klinika - headaches - they can find it overwhelming, when they get caught, when they walk, when they walk, when they see them, or the noise in the winds, etc.

Pains in the area of ​​the heart - in addition to intensive, often in the area of ​​the upper heart, there are people who are not connected with physical pressure; may be trivial, which do not stop nitrates, are not altered by taking sedatives

sercebittya

2. Objectively: there may be an increase in the mass of tila, with the development of CHF - acrocyanosis, sluggishness, peripheral swelling, percussion between the hearts - expansion of the myocardium.

In the diagnostics of the AG, there are two levels of patient compliance:

A) outpatient - the plan for the treatment:

1) laboratory methods: OAK, OAM, BAC (lipid, cholesterol, glucose, sechovina, creatine, proteinogram, elektrolyti - kaliy, sodium, calcium)

2) Instrumental methods: - EKG (for assessing the degree of myocardial hypertrophy, determining ischemic changes)

Rheoencephalography (for the type of cerebral hemodynamics) - X-ray of the organs of the breast, - examination of the face-to-face by an ophthalmologist, - nasal test

If possible, bazhano viconati is also: Echo-KG, ultrasound nirok, doslіdzhennya thyroid gland, Tetrapolar rheoplasmography (for the type of hemodynamic impairment)

B) stationary: to see the additional provision of the patient usim by any means With the help of the AG's approval and the establishment of stability, the introduction of secondary activities, the development of factors in the risk, the reduction of organ-targets, and the corresponding clinical stan- dards.

For a quote: Lupanov V.P. Stratification of the rhizic of the heart-vascular disease in ailments to a stable coronary ailment of the heart (oglyad) // RMZ. 2014. No. 23. S. 1664

The pre-state prognosis of stable coronary heart disease (SCBS) is based on a number of factors, such as clinical and demographic changes, as a function of the function of a loner (LH), the results of stress testing by anatomical methods and coronary

Before the hour of negotiating the stratification of the rizik among the patients with the SKBS, the rizik should be considered for everything before the heart-judgment death and myocardial infarction (IM), I would like to see the children of the early combatants of the victorious to fight The most obvious hard point is death, the point of death, including IM, to be tolerated to the weak, even though it is guilty of being a critical principle of the strategy of podiatry. The process of stratifying the risk is to serve for the detection of patients with a high pod, which removes the corny due to revascularization of the myocardium in conjunction with weakened symptoms.
The designation of ailments of a group of high rhiziks, as they eliminate unchallenged corystiness from revascularization, which remained an hour in the wake of the previous version European recommendations... Earlier, a high risk of heart death was primed only at the sum of scores that were removed during a thread test according to the Bruce protocol, and> 2% ... The value of the index is based on heart-vascular mortality in the group of placebo-illnesses, carried out in patients with a "high risk", such as patients with diabetic microalbumines, with heart-to-heart diseases Preceding Hope and Micro-Hope and friendly infusion of nicorandil with stable angina pectoris heart-and-heart disease was more than 2%.
New European methodical recommendations In 2013, the patients with the transfer of mortality more than 3% of the SKBS patients should be close to the group of high risk of death.

Strategies for the policy assessment
History of ailments and physical illness of a patient may provide important prognostic information. The EHC may be included in the strategy for the development of the laboratory dosages, I can change the assessment of the quality of the pod. Diabetes, arterial hypertension, palynia and adolescence of chronic cholesterol (unaffected by the disease) can predict an unpleasant result in a patient with SKBS, or in some groups of the population with the establishment of the IXS. abduction vikє An important factor in order to detect the presence of chronic illnesses or diseases of peripheral Sudins. IM transfers, symptoms and signs of heart failure and the nature of the leak (a recent ear or a progressive interruption with a flared a clever picture), And also the severity of angina pectoris (functional class according to the Canadian classification), especially if the patient does not appear to be optimal drug therapy, You can buy vicoristani for assessing the risk of podіy.
However, the information has been re-secured and is foldable, it will be brown for the assessment of the risk and forecast of the future. To that the victorious test of clinical data, especially the severity of angina pectoris, is necessary in the complex with the results of the preliminary test of the hemophilia on the basis of the largest non-invasive methods of assessment and with the data of the CAG.

Stratification of riziks with vicarious functions of shlunochkiv
A strong predictor of survival in the pre-construction perspective є the function of LSH. In patients with SKBS, with a low fraction of LSh, the mortality rate increases. In pre-illnesses from surgery of coronary arteries (CSS) 12-fold survival rate of patients with EF ≥50%, 35-49% and<35% была равна 73, 54 и 21% соответственно (р<0,0001). Таким образом, у пациентов с ФВ ЛЖ <50% уже определяется высокий риск смерти от сердечно-сосудистых заболеваний (ежегодная смертность >3%), to navigate without urahuvannya additional factors, such as steps of myocardial ischemia. For these patients, the samples should be replaced with dosed physical adjustments following the method of stress-visualization. If I want to preserve systolic function, it is highly recommended for patients with normal ECG, a normal X-ray and a daily history of IM, asymptomatic myocardial dysfunction is not recommended for the recurrent

Stress testing
Ailments with symptoms of SKBS, for I will undergo a stress test for no reason to undergo stress testing with the help of a strategy of development. The results can be used as candidates for the treatment of therapeutic solutions, as candidates for coronary revascularization. However, there are some randomized tests that have been shown to have abrupt results for patients who have been randomized for assessing the results of tests for stress testing, for those who have not been tested for such tests. ... There are a lot of patients who undergo diagnostics testing, in any case, and the result can be a test for stratification. Patients with a high degree of anterior test (> 85%), who underwent an earlier invasive CAG for symptomatic reasons, may be necessary, if necessary, to develop a fractional reservoir coronary blood flow for stratifying coronary blood flow.

EKG-stress-testing
The forecast for patients with a normal EKG-breakdown with new options and low classroom risk is often based on the prognosis of ailments with the importance of SKBS. A total of 37% of outpatient ailments recruited for non-invasive testing met the criteria for a low risk of coronary heart disease, ale mal (less than 1% of patients) the extent of the main stem of the LKA and 3
Simple methods of advancement, such as a thread test, if it is possible, are guilty of being stuck for cob stratification of pods, and especially with a high risk should be sent to CAG.
Prognostic markers of antihypertensive test include: tolerance to physical antioxidant, AT reaction when antihypertensives and symptoms of myocardial ischemia (key or EKG-indications), maximum tolerance. Tolerance until the new option is taken to lie in part of the stage of dysfunction of the little ones in the calm and from the number of new hypokinetic segments of the LSh, which are induced on the option. Protest, tolerance to physical growth can also be found in the form of a physical patient's camp, a patient's illness and a psychological camp. Tolerance to physical pressure can be adjusted to the maximum level of triviality to the right, the maximum metabolic equivalent is reached, the oxygenation of tissue is adjusted in one hour, estimates of the level of the maximum voltage For a non-invasive assessment of the forecast, a wider expansion of the counting points, D.B. Mark and spivavt. , Win is called a treadmill score of the Duke University (Duke treadmill score). Evaluation of Duke's index according to the treadmill test - a good change in the indicator, vin vrahovuє: A - triviality of new options (in chilins); B - displaying from the ST segment in millimeters (before the hour is finished or when it is completed); C - index of angina pectoris (0 - angina pectoris with no bulging; 1 - angina pectoris appeared; 2 - angina pectoris served as the cause of the delay). Treadmill-index = A- (5 × B) - (4 × C).

With a very high risk of transmission of mortality (more than 2%), it should be accounted for by a special scale. An estimate of the risk of development of IM and deaths according to the thread index is shown in Table 1.
Patients with a high risik are shown myocardial revascularization. Patients from the middle risik carry out the visualization methods. If it is normal or close to normal myocardial perfusion in the presence of normal heart sizes in the absence of normal heart sizes, it is necessary to familiarize patients with a friendly prognosis, patients are recommended to take medication for treatment, and in case of manifestation, it is dysfunctional.
Patients with a low risk are far away from stress-imaging techniques and coronary angiography to be underestimated, it is recommended to take medication for treatment.

Stress echocardiography
Stress-echocardiography - visually detecting local dysfunction of the LH from the hour of physical therapy or pharmacological test - is an effective method for stratifying patients in the SKBS on the group of patients with further heart-bones. In addition, the whole method can show a negative predictive value in patients with a negative test result (without the appearance of abnormal breakdowns of the LH wall) - the frequency of cases (death or IM) becomes less than 0.5% in ric. In patients with normal functioning of the LH on the cob, the development of the risk of the developmental stage of growth is due to the development of the abnormalities of the wall of the wall during the replacement. Patients with the appearance of a collapse of the wall in 3 and more segments from 17 standard models of LSH should be seen as a high risk of the development (the general mortality rate> 3%), for which the CAG is to blame. In addition, the stress-EchoKG technique allows for the detection of symptom-related coronary artery by the localization of the zone and the associated LS dysfunction.
Stress perfusion scintigraphy (single-photon emitting Computer tomography(OFFECT)). Perfusion scintigraphy of the myocardium is designated for the assessment of blood flow of the myocardium at the level of microcirculation. The rate of failure of myocardial perfusion after data on anti-cancer scintigraphy talk about a friendly prognosis when reporting chronic SCBS, and about a deteriorated perfusion about an uncomfortable prognosis to get lost.
Vizualization of myocardial perfusion in the form of an OFECT corny method of non-invasive risk-strategy, so that it is easy to find quiet patients, as it is possible for the greatest mortality to suffer. Great clinical preliminaries have shown that normal perfusion during replacement is associated with a lower heart death rate and IM less than 1% in the population, which is so low as in the population as a whole. On the whole, great stress-induced perfusion defects, defects in the decile main coronary basins, bypassing post-stress ischemic dilatation of the LH and due to the failure of the indicator to follow - by the delayed chlorine Pre-treatment of myocardial perfusion is shown to all ailments with chronic SCBS for stratifying the development of heart-vascular acceleration.

Positron-emitting tomography (PET) allows a non-invasive way to remove information on the basis of microcirculation and speed of metabolic processes in cardiomyocytes. PETS of the best image quality, presenting a lot of information about myocardial blood and clinical perfusion of the heart. Pre-session in calm and in combination with stress infusions (vasodilators) I wanted to bring high sensitivityі specificity in chronic SKBS, everywhere does not become stagnant.
Electron-exchange tomography in the diagnosis of atherosclerotic lesions of the heart, especially when verifying multivessel atherosclerosis and lesions of a stool of the heart. However, the technique is inaccessible for all-round stasis, the road, a number of obmezhen, to that the completeness of carrying out the diagnosis in chronic SKBS has not yet been brought.
Stress-heart magnetic resonance - magnetic resonance imaging (MRI). In case of high-factor analysis, there was an independent association with an uncomfortable prognosis in patients with a positive stress-MRI result and 99% of survival in patients without ischemia at a 36-month delay. Additional results were taken during the test for the assessment of perfusion MRI tests with adenosine triphosphate. The appearance of new breakdowns of the LH myocardium (in 3 of 17 segments) or if a perfusion defect appears> 10% (more than 2 segments) of the LH myocardium area can be introduced into the upper rhizik.
Multispiral computer tomography (MSCT). Screening of calcification of coronary arteries for additional MSCT is used to determine the value of coronary calcium. Calcifications are seen through high rates of maturity to blood and walls of the sudins. A high level of calcium index is associated with a significantly greater risk of obstructive lesion of the coronary bed.
MSCT of coronary arteries with contrasts in a large number of cases allows the appearance of atherosclerotic plaques, as well as the presence of stages of intravascular stenosis. In ailments who had undergone coronary artery bypass surgery earlier, the whole method of additional assistance to assess the progression of arterial and venous shunts. According to the data of the great meta-analysis, assigned to the accuracy of non-invasive diagnostics of the stage of stenosis of the CA behind the additional MSCT with 64 rows of detectors in the sample of CAH, which included 3142 patients with a dose rate of 83% - 89% - 89% 91 -96%). In addition, the MSCT method, having demonstrated a highly negative predictive accuracy for the inclusion of occlusive patches of CA, yak, according to the data of recent authors, becomes 97% to 100%. MSCT allows the assessment of the external and internal contours of the artery, anomalies and aneurysms of the coronary arteries. In young patients with multiple calcified internal vascular plaques, the method should be carried out prior to hyperdiagnostics of coronary artery stenosis.
Pidsumkova stratification riziku accelerated in the ailments of the SKBS. kintsevoy metoyu non-invasive diagnostics є raised ailments with an increased ІХС in a group: with a high, dim or low rhizik of important delayed and fatal inheritances (Table 2). Table 2 should have American (2012) and European (2013) recommendations.

The stratification of patients for a group of patients is of less practical importance, some of them permitting the identification of unnecessary advanced diagnostics and the speed of medical vitrati in some patients to rehabilitate actively Revascularization of the myocardium is correct, as it is cleansed out of measles, from the point of view of vision of any indicators of health (symptoms, functional status and / or quality of life), and will change the detection of negative inheritance procedures. Vibrant on the whole an important aspect of the clinical practice, Yakі may mean values ​​і for patients, і for ailments, є assessment of risik. The perspectives will allow you to control the quality and assess the economic aspects of health, as well as to assist you to the carers, to install and to the vital organs to assess and repair the robot. In a group with a low rhizik, it is faster (the death rate is<1%) проведение дополнительных визуализирующих исследований с диагностической целью не оправданно. Также нет необходимости в рутинном направлении таких больных на КАГ. Больных с высоким риском осложнений (предполагаемая ежегодная смертность >3%) were sent to CAG without further non-invasive information. In ailments, living up to the group of those who are less than rhizic (the percentage of mortality is 1-3%), it is shown before CAH to start following the results of early adolescents (visualizing stress, perfusion scintigraphy for myocardial dysfunction) However, an individual forecast of a particular ailment SKBS can be varied in the presence of the main clinical, functional and anatomical characteristics.

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Table 3

Note:

* The accuracy of the value of the zagalny heart-vascular rhizik must be laid down without the need for more clinical and instrumental and biological treatment of the ailment. Without data, ultrasound of the heart and sudin for the diagnosis of HLS and the increase of the stage (or the presence of plaque) of sleepy arteries up to 50% of AH ailments can be reduced to a low or middle risk to replace a high a; ** add. - dodatkovy rizik

Patients with a high and a high rizik

Table 4

* GFR according to MDRD formula (ml / hv / 1.73 m 2) = 186 x (creatinine / 88, μmol / l) -1.154 x (vik, rocky) -0.203 for women, multiply the result by 0.742

** Clearance to creatine according to the Cockcroft-Gault formula = (88 x (140 - vik, rocky) x mass, kg (ml / hv)) / (72 x creatine, μmol / l) for women, multiply the result by 0.85

diagnosis formulation

When the diagnosis was formulated according to the possibility, the most likely to blame, the appearance of FR, POM, AKS, heart-vascular rhizic was displayed. The step of advancing the arterial clutch is obligatory for the children to be diagnosed with the AG, for those who are ill, it is necessary to write the age of the great aggravation, which in Russia There is a three-stage classification of GB, GBI stage of transferring the visibility of PZZ, GB of II stage - the presence of changes from the side of one or even decile organ-targets. diagnosis of GB III stage to get up at the presence of the AKC.

When the AKS is out, the term "hypertensive ailment", due to its high prognostic significance, naturally borrows the first position in the structure of diagnostics. With the presence of the AKC, it is supervised by a high level of damage to the function, or it will state form, For example, gostry coronary syndrome(GCS), "hypertensive ailment" in the structure of the diagnosis of heart-vascular pathology can not be considered.

Apply the diagnosis formula:

GB stage I. Stage of hypertension 2. Dyslipidemia. Rizik 2 (middle).

GB II stage. Stage of hypertension 3. Dyslipidemia. GLSH. Rizik 4 (even temple).

GB III stage. Stage AG 2. IXC. Angina pectoris II FC. Rizik 4 (arch high).

GB stage I. Stage AG 1. SD type 2. Rizik 3 (high).

IXC. Angina pectoris III FC. Postinfarction (velikovischevy) and atherosclerotic cardiosclerosis. GB III stage. The feet of AG 1 are reached. Rizik 4 (arch high).

GB II stage. Stage of hypertension 3. Dyslipidemia. GLSH. Obesity II Art. Loss of glucose tolerance. Rizik 4 (arch high).

Pheochromocytoma of the right nadirnik. AG 3 steps. GLSH. Rizik 4 (even temple).

Ethiology

There are a lot of previous ones to see the following formulas: sensitive hypertension (EH) may be the result of the interrelationship of recessionary officials, who are screwing up to hypertensive reactions in recent years

in 81% of ailments, the relatives of mali have an arterial vise. Spadkovi factors, which can be brought up to the development of the EG, can be brought up to the sphere of the central regulation of the arterial vise / "stress geni" /.

From the clinical practice of the form EG, from the point of view of G.F. Langa, є the inheritance of mental overstrain, pouring into his mental sphere of emotional negative character, mental traumatization.

Recessively oversized sensibility to kitchen salt and salt appetite.

Metabolic health effects Obesity - it is seen as one of the provincial officials of the formation of the GB of the middle of the inhabitants of economically developed regions.

EG is recognized to the number of the most widespread diseases of the heart-vascular system: it becomes 95% of all types of hypertension. Secondly, it was taken in respect of the AG, which is the result of the primary control of the organisms. For the data of epіdemiologicheskih doslіdzhen, held in іznih lands, the stench is stored 5-6% of the middle of the sick, who are suffering on the AG.

pathogenesis

Yak vіdomo, rіven arterial vise is used to relieve the heart vikidu blood and peripheral vascular support. The development of arterial hypertension can be inherited:

pidvischennya peripheral support, poured spasm of peripheral sudin;

the improvement of the blood-thinning of the heart as a result of the intensification of the robot and the growth of the internal vascular volume of the child (accumulated with sodium in the body);

the addition of an increased amount of sinewy lassitude and the advancement of the peripheral support.

In normal minds, the growth of the chilinous volume is reduced to the lowering of the peripheral support, as a result of which the arterial grip does not move. Thus, the regulation of the arterial grip becomes the optimal control of the pressor and depressor systems to the body.

To the pressor system, carry:

sympathetic-adrenal (SAS);

renin-angiotensinov (RAS);

aldosterone;

antidiuretic hormone system (vasopresin);

system of prostaglandin Fa * and cyclic nucleotides.

The depressor system includes:

aortocarotid zone (reflexion from which leads to a decrease in the arterial vise);

system of depressed prostaglandins;

kalikrein-kininovu system;

atrial natriuretic factor;

endothelium dependent relaxing factor.

In case of hypertensive ailments є the failure of the pressor and depressor systems in young people, there is an increase in the activity of the pressor system and a decrease in the activity of the depressor systems.

For not tsіlkom yasnim causes in ailments on GC pіdvischuєtsya pressor aktivnіst gіpotalamo-gіpofіzarnoї Zoni, scho Veda to gіperproduktsії kateholamіnіv (pіdvischena aktivnіst CAC), about scho svіdchit pіdvischennya dobovoї ekskretsії of secheyu noradrenalіnu scho slit in bіlshіy mіrі zrostaє in Minds fіzichnogo that emotsіynogo stresu ...

The result of the activation of CACє These are the changes that zoom in on the arterial vise:

peripheral venoconstruction supervises the increase in blood flow to the heart and heart wikidu;

the growth of the number of hearts is very fast, but in the same period with the increased shock volume, it is also the same until the increase in the heart wikidu;

growth of the posterior peripheral op_r of sudin due to the act_vats__ Pi-receptors in the peripheral arterioles.

Quite a few middle factors of the loan are the activation of the RAS. Alterations in the place of AT II in the blood plasma of the wiklica trivial spasm of smooth muscles of the peripheral arterioles and rіzke pіdvischennya OPS.

AT II pouring into іnshі fresh systems: 1) vyklyuchi spragu, vіn veda until podvischennya vyroblenya vasopressin, which is a zumovlyu spasm of sudin і overlap the rіdini in the body; 2) activating aldosterone - the hormone of measles supra-nasal vulvais, which will increase the absorption of sodium and water into the body (increase the mass of circulating blood).

Trivial spasm of arterioles spraying in the place of Ca ++ ions in the cytoplasm of smooth fibers, which is tied to the spasmodic zooming peculiarities of the transport of ions through the penetrating membranes.

Pіdvischennya aktivnostі presornih faktorіv poєdnuєtsya of attenuation depresornih vplivіv of the aortic arch i sinocarotid Zoni, zmenshennyam viroblennya kіnіnіv, nedostatnoyu aktivatsієyu viroblennya peredserdnogo natrіyuretichnogo i endotelіyzalezhnogo relaxing faktorіv, zmenshennyam vidіlennya prostaglandinіv scho volodіyut depresornі vplivom (E2, D, A) i prostatsiklіnu L zmenshennyam viroblasting ingibitor renin - a phospholipid peptide.

The pathogenesis of hyperadrenergic and sodium (obsyag) depleted forms of GB is always seen in the pathogenesis of this type of lanka. They stay for an hour to see the calciferous form of the ailment.

clinika

skargi:

headaches;

noise, dzv_n in vuhah;

zamorochennya;

stomachache;

I have a pain in the heart;

interruptions in the robotic heart.

Syndromes that characterize the heart disease:

syndrome of myocardial damage (hypertrophy);

arithmic syndrome.

Syndromes that characterize the damage to organs and systems:

chronic heart failure syndrome;

cerebral syndrome (hemorrhage in the brain).

A typical picture of arterial hypertension:

Most early and long-term skargs on headaches... To embrace, dull wounds in the middle of the day, grow weak until the middle of the day, pulsating heat pains in time, heaviness in the forehead and early eyes of the head in the evenings, "unclear", clouded, "dull" head. It is more to be accommodated in case of rationalization and physical adaptation. Between the arterial grip and the intensity of the headaches, do not depend on the acute parallelism, perhaps because the pain relief is sub-active.

Pidvischennya arterial vise, crimson headache, can supervise noise and zenkot v heads and wuhah, pawn wuh, zamorochennyam with blues.

Strengthen the reception of healthy and hearing aids. Patients are often turbulent at the sight of the viglyad "Shroud", migotinnya "fly" in the field of view, you can have a diplopia and a vipadannya of a field of view.

Hvorі skary on I have a pain in the area of ​​the heart. More, clearly connected with the AT pidyomas, in their own way, because of the seriousness in the area of ​​heart, triviality, in general, the weakness in the world of lower arterial grip.

Re-entangling the heart with a vice is often done until the skarg appears on heartbreak, interruptions in the robot heart.

Skargi to tell you about the development of heart failure. Zadishka can be illuvated stepwise or paroxysmal / heart asthma /.

at callous look It is a good one to be identified by the sheer curvatures. Often, there is a trace of a trace of a high peripheral support for a rakhunok spasm of the sudin with a low heart wikidi. If AG is supervised by a high heart wikid, then the compensatory expansion of the capillaries of the shkiri can lead to hyperemia. In such a vipadku re

Nadlishkova masa tila. In this hour, a wider expansion in the designation of the excess mass of tila has neglected the formula for the index of mass tila / ІМС, kg / m 2 / = mass (kg) / sp_st (m 2).

Inspection of the region of the heart vyavlya the change of the position of the top post. In case of concentric hypertrophy, it may or may not be in accordance with the norms. Zsuv of the highest postage is called spostering deprivation during the dilatation of the lavochka. In the whole range of high-end shipments, it is not only left, but downward. In case of hypertrophy of the meat of the lithic lid, the upper post razlitiy (more than 2 cm 2), high, perfection ("raising" or "dome-like").

The shaping of exchange arteries makes it possible to assess the character of their pulsations. The pulse becomes firm ( p. durus), Let's turn ( p. plenus), Great ( p. magnus), May be smart ( p. celer).

at percussion to replace the cordon with a single dullness of the heart, for the rakhunok of the growth of the livy dumbbell. The heart grows in diameter, and then in the length. The configuration of the heart appears to be aortic.

Auscultatory with an increase in the hypertrophy of the lilac duck, the sweetness of the I tone at the top of the heart decreases. Good vidomii sign of the development of an arterial vise - the emphasis of the second tone on the aorta. Yakshcho vin is a musical (tympanic) type of display, then it is due to the seriousness and triviality of hypertension, as well as to the reduction of the aorta.

Auscultatory method of viznachennya arterial vise behind the aid of the tonometer, fragmentation of N.S. We are short, to become the main method, to be stuck in the classroom practice.

Diagnostic program

Cycle of ailments AH:

to confirm the stability of the arterial vise;

viciousness of the secondary nature of AT;

to establish factories of AT risk;

to assess the appearance of certain organ-targets, heart-judges and others who are ill;

assessment of individual steps of the IXC and heart-vascular acceleration.

Outside physical dosage includes:

2-3 times vim_ryuvannya arterial vise;

rosrakhunok index masi tila;

full-time screening for the stage of retinopathy;

advancement of the heart-vascular system: heart breakdown, change of tones, appearance of noise; signs of heart failure; pathology of arteries;

drowsiness of legends (wheezing);

doslіdzhennya black empty(Sudden noise, increased nirok, pathological pulsation of the aorta);

delayed pulsation of peripheral arteries, appearance of embryos;

doslіdzhennya nervous system to clarify the presence of cerebrovascular pathology.

Obov'yazkovі doslіdzhennya, which is carried out with the method of detecting the defeat of the organs of targets and officials:

analysis of the section;

zagalny blood analysis;

blood sugar;

biochemical analysis of blood (calcium, sodium, creatinine, glucose, cholesterol, lipoproteins of high grade);

EKG in 12 entries.

Dodatkovy methods of preschooling:

roentgenologic provision of breast organs. At the period of the cob, concentric hypertrophy, it can be deprived of the rounded upper part of the lone slut. In case of a large turn of the hypertrophy of the lower part of the Legeny field, the upper part of the lower part of the Legeny field drops slightly to the bottom and changes. On the roentgenogram in the middle projection, it is possible to increase the size of the lower half of the arch from the half of the segment of the half-cut close to 10 cm and the large diameter up to 16 cm, as well as the increase in the diameter of the heart;

EXO-KG - the greatest specificity (90%) and sensitivity (90%) in the presence of hypertrophy of the louse. Signs of hypertrophy are to serve as a sign of the back wall of a little louse і / or a mid-section partition up to a size of 10-11 mm;

the post-mortem examination of the bottom allows the assessment of the steps of the microcirculatory bed (hypertensive angioretinopathy);

Ultrasound nirok;

ultrasonography of arteries;

angiography.

Differential diagnosis

Differential diagnosis of hypertension should be performed with secondary hypertension.

Table 5

lykuvannya

Meta likuvannya hvorikh AG - the maximum reduction of the heart-vessel disease and lethality, which is not only a decrease in AT, but ale and correction of all the emerging officials of the disease.

Principles of non-drug treatment:

vidmova vid kurinnya;

reduction of excess weight;

reduction in the consumption of kitchen salt (up to 4.5 g / dobu);

reduction in ethanol consumption (for people 20-30 g ethanol per day, for women 10-20 g);

modification of food (increase in the production of vegetables, fruits, seafood, food fat);

improvement of physical activity (walking, swimming).

Principles of drug therapy:

ear of lіkuvannya with minimum doses of one drug;

with a lack of effect of one drug (maximum dose), go to the drug in the first class;

vikoristannya poєdnan preparations_v for reaching the maximum effect.

Check two scales for assessing CVD risk - a scale based on the results of the Framingham Preschool, which allows the development of 10-day risk of diagnosing the main coronary heart disease (death due to the IXC, non-fatal heart disease) System Yes Coronary - rіchny risik vyniknennya fatal heart-vascular podіy. The SCORE scale is designated for the purpose of the primary prevention strategy for the patients of the European population. Vona vrahovuє rizik not only ІХС, ale and all heart-vascular podіy, beruchs to respect the coronary and non-coronary factor rizik.

To assess the risk of CVD development, it is optimal to use the SCORE scale, as it should be guided in the European Recommendations for the prevention of CVD.

Riziku scoring system SCORE

All the significant indicators of the whole system were rooted at the presentations of the 12 European Epidemiological Dosages. The system is represented by two tables for the development of the country with low and high rivne. In addition to the color scale for the level of risk, the skin graphic is to replace the number for a more accurate assessment of the risk. It was an indicator of the risk of death in the first 10 years of the life of a patient. For a high risik, the figure is 5% or more.

Priority groups of patients for the prevention of CVD (European recommendations 2003):

1. Patients with manifestations of coronary, peripheral and cerebral atherosclerosis.
2. Patients without CVD symptoms, even with a high risk of developing fatal deaths through:
   • the number of decliners in the risk of death (the rate of development of fatal deaths in the nearest 10 years is ≥ 5%)
   • Significantly prevalent single factors in risik (cholesterol ≥ 8 mmol / l, LDL cholesterol ≥ 6 mmol / l)
   • AT ≥ 180/110 mm Hg. Art.
   • red diabetes type 2 or type 1 with microalbuminurin.
3. Close relatives of patients with early development of CVD.

Below are the color tables for CVD development. They vrahovuєtsya become a patient, vіk, rіven zalalnye cholesterol, arterial vise, kurіnnya. Green color means low rhizik, dark brown - high (Table 3).

Table 3. Table of 10-rate fatal CVD risk (European Society of Cardiologists, 2003 (12 European cohorts, including Russia))

Slid means, for the risk of CVD, insurance under SCORE, there can be underestimations if:

• The courtesy of the summer patient
• preclinical atherosclerosis
• unwelcoming slump
• Reduced HDL cholesterol, increased TG, CRP, apoB / Lp (a)
• Obese and hypoodynamic.

Criteria, on the basis of which visas start the incidence of CVD risk

: Evidence of 2 or more factors in the diagnosis in the diagnosis of ІHS (myocardial infarction, unstable angina pectoris, stable angina pectoris, underwent surgery for coronary bypass surgery and transluminal coronary angioplasty, documents Before Visoko riziku takozh vіdnosyatsya nayavnіst 2 i bіlshe faktorіv riziku in poєdnannі of zahvoryuvannyami, ekvіvalentnimi by step riziku ІHS: more peripheral atherosclerosis nizhnіh kіntsіvok, aortic aneurysm, atherosclerosis sonnih arterіy (transient іshemіchna attack abo іnsult vnaslіdok urazhennya sonnih arterіy abo zvuzhennya prosvіtu sonnoї arterії > 50%), diabetes mellitus. Rizik development of important ІХС with a stretch of 10 rockets> 20%.

: The availability of 2 and more factors in the risk. Rizik development of important ІХС with a stretch of 10 rocky 10-20%.

the appearance of 2 and more factors in the risk. Rizik development of important ІХС with a stretch of 10 rocks<10%.

: 0-1 factor of risiku. The assessment of the IXC risk among the group is not obov'yazkov.

The main factors of risk, such as injecting LDL cholesterol into the tins, є (NCEP ATP III):

• cigarette smoking
• Hypertension (AT is more than 140/90 mm Hg. Art.)
• Low level of HDL cholesterol (<40 мг/дл)
• Early development of IXC in family anamnesis (1 stage of dispute; up to 55 years in choloviks, up to 65 times in women)
• Вік (people over 45 years old, women over 55 years old)

Let it mean that, in the Danish hour, they are far-fetched, and so called new and unfinished factories:

• triglyceridi
• remnant of lipoproteins
• Lipoproteide (a)
• Small particles of LDL
• type of LGP
• Apolipoprotein: In and A-I
• Shutter: LDL cholesterol / HDL cholesterol

• homocysteine
• Thrombogenic / antithrombogenic factors (thrombocytes and factors of throat, fibrinogen, activating factor VII, inhibitor of activating plasminogen-1, tissue activator of plasminogen, Villebrand factor, factor V Leiden, protein III, antithrombin)
• factories
• Addition of glucose for food

Riven cholesterol, LDL cholesterol, HDL cholesterol can also be used to determine the risk of CVD (Table 4).

Table 4. The value of the CVD risk on the basis of the lipid profile of LDL cholesterol (mmol / l)

Malunok 8. The tactics of conducting patients without clinical manifestations of IXS and CVDs, based on the category of risk management


In such a rank, the rozrakhunok riziku for a particular sick person is guilty of being carried out in all vypadki. Apparently, the recommendations and tactics of dealing with the blame for the inconveniences of the disease, as well as the Danish pidhid, allows the reduction of the incidence of the CVD and the delay.

List of Literature

1. EUROPEAN GUIDELINES ON CVD PREVENTION Third joint European societies' task force on cardiovascular disease prevention in clinical practice, 2003
2. NCEP ATPIII: JAMA, May 16, 2001., 285 (19), p. 2486-97

7697 0

In connection with this, the prognosis in patients with stable angina may be highly variable, and the current strategy of treatment has significantly expanded - from symptomatic therapy to high-tech and expensive methods, old ones, stable angina. With the help of the risky, the reason was heart-and-death death and IM, and in some cases, and in some cases, heart-and-heart inheritance.

The process of stratifying the risk is transferred to two types:

• feedback on food from the drive of the forecast, as they are found by the ailments themselves, robot teachers, insurance companies, licensed specialties, who are involved in the diseases of their fellow patients;
• vibrate adequately lykuvannya.

With the victorious methods of treatment, especially revascularization and / or intensive pharmacotherapy, the prediction can only be reached in the singing groups of patients with high rhizik, at that time, in the case of the first few patients In connection with the cym, it is necessary to see the patients, to be brought to the group of high rhizik, in some of the most imovir the cinnamon is more aggressive in the early stage of the situation.

In the recommendations of the EOK (2006), the criterion for high risk is a heart-vascular mortality rate of more than 2%, an average risk of less than 1-2% and a low risk of less than 1% in a week. Until now, a practical model for assessing the risk has not been broken down, but it includes all possible aspects of the strategy, possibly alternative ideas, based on the results of clinical reports. As soon as possible, all ailments need to carry out critical care, more - non-invasive follow-ups with the help of an assessment of the functions of the LH and - to fix them.

1. Stratification of rizik on the presentation of key donations

The history of the ailment and the results of the physical routine allow to correct more importantly predictive information. At the end of the day for stratification, there can be EHC vicarians and laboratory tests, pererakhovani vishche. It was established that there was diabetes, arterial hypertension, MS, hypertension and hypercholesterolemia, allowing the transfer of development of uncomfortable inheritance in ailments with stable angina and with manifestations of the second. Unwelcome prognostic value of ma vіk, as well as transfers ІМ, symptoms of heart failure, the nature of overturning angina pectoris (firstly, it is progressive) and ії severity, especially when there is a reason for symptoms. The peculiarities of attacks of angina pectoris, their frequency and manifestation of EKG-changes in calmness are important predictors of death and IM. At the display of these indications, it is possible to develop a simple index, which allows the transfer of unpleasant inheritances, especially by reaching out to the most fate.

Physical conditions are also additional help in assessment. The detection of peripheral vascular disease (lower symptoms or sleepy arteries) is instrumental in the development of heart disease in patients with stable angina pectoris. Unfriendly prognostic factors include such symptoms of heart failure, which add to the function of the LH.

In patients with stable angina pectoris, in those who have symptoms of EKG at rest (signs of a postponed IM, blockade of the left lower part of the Gus bundle, hypertrophy of the LS, AV block of II-III stages abo FP), rhizic of the heart and vascular disease EKG.

2. Stratification of risk for additional stress tests

The prognostic value of these samples may not only start with the detection of myocardial myocardium as such, but the assessment of the threshold for development, the breadth and severity of obvious changes (EHCG and scintigraphy) and transferability. The results of stress tests did not follow from the clinics' tributes. In such a rank, navantazhuvalny probes allow you to correct additional information about the heart-vascular rhizic in a particular patient.

2.1. EKG s navantazhennyam

One hour, the results of anti-aging tests and key parameters, as well as the distribution of predictive indexes, such as Duke's index, were found to be an effective approach to the stratification of ailments in the IXC of such a group. The Duke Index is an index that can be used at the end of the day for delivery, for the removal of the ST segment and for the diagnosis of angina pectoris in the event of replacement.

Rozrakhunok tredmil-index, JACC, 1999 ..

Treadmill-index = A - -,

de A - the triviality of new options and hilines; B - the output of the ST segment in millimeters (in the course of completion and after completion); C - index of angina pectoris;

0 - angina pectoris;

1 - angina pectoris є;

2 - stenocardia to produce up to zupinka doslіdzhennya.

2.2. Stress echocardiography

Stress EchoKG is also possible with the success of the vicarist for the stratification of the heart-vascular acceleration. In case of a negative test result, the incidence of unpleasant inheritance (death or IM) becomes less than 0.5% in ric. Rizik factor is the number of regional rapidity breakdowns in calmness and at navantazhenny (what is more, tim vische risik). The vision of a visitor of a high risk allows the food to be seen as far away as possible.

2.3. Myocardial perfusion scintigraphy

Normal results with high ymovіrnіstyu indicate a friendly prognosis. Navpaki, the deterioration of perfusion is associated with the important IXC and a high heart-vascular rhizik. Great and widening of perfusion defects, which occur during stress tests, past the ischemic dilatation of LSH for the test and the accumulation of ² ° Тl in the legends due to the increase in the pharmacological progression of the probable problem.

3. Stratification of risik on the premises of the function of shlunochkiv

The most important predictor of vision for the given term is the LS function. In ailments, stable angina pectoris mortality is increasing in the world of a decrease in the fraction of the LSh. With a fraction of wikid in calm, less than 35%, the mortality rate is 3%. The size of shlunochkiv is also more important in predictive value, as I will reverse the results of nasal tests in patients with stable angina pectoris.

4. Stratification of rhizik on the presentation of coronary angiography

The breadth, severity and localization of stenosis of the coronary arteries may be more important prognostic values ​​in patients with angina pectoris.

In the CASS registrar, the 12-day survival rate on the same drug therapy was 91% in patients with unimpeded coronary arteries, and 74% in patients with injured one judge. two - 59% and three - 50% (p<0,001). У больных с выраженным стенозом главного ствола коронарной артерии, получающих фармакотерапию, прогноз неблагоприятный. Наличие тяжёлого проксимального стеноза левой передней нисходящей артерии также значительно снижает выживаемость.

Pozdnyakov Yu.M., Martsevich S.Yu., Koltunov I.V., Urinsky A.M.

stable angina