IHD and stress angina in the ICD-10 have its place. There are diseases, which are based on violations in the process of blood flow to the muscle of the heart. Such diseases are called ischemic heart disease. A separate place in this group occupies angina, as it signals that the patient's condition is dangerous. The disease itself does not lead to death, but it is the predecessor of the ailments that have a deadly outcome.

Adopted international classification

In international documentation, the IBS occupies categories from I20 to I25. I20 is angina, which is also called chest toas. If it is not stable, then the number 20.0 is indicated. In this case, it can be increasing, as well as the stress angina, both for the first time arising and in the progressive stage. For a disease, which is also characterized by spasms, number 20.1 is installed. In this case, the disease may be angiospastic, variant, spashed or printed-in syndrome. The remaining varieties of the disease are indicated at number 20.8, and if pathology is never clarified, then cipher 20.9 is used.

If the patient has an acute stage of myocardial infarction, then this is a section I21. This includes a refined acute ailment or established within a month (but no more than). Some side effects are excluded after a heart attack, as well as the disease transferred in the past, chronic, lasting more than a month, as well as the next one. In addition, this section does not include post-infarction syndromes.

If the patient has a repeated myocardial infarction, then this is a section I22. Such a cipher is used for all varieties of myocardial infarction, which is localized anywhere, but occurs within 28 days from the moment of the first attack. This includes recurrent, repeated and growing species. But a chronic state is excluded. For some current complications of acute myocardial infarction, section I23 is used.

The classification includes other forms of acute ischemic heart disease. All information about this is contained in section I24. If a patient has a coronary type thrombosis that does not lead to myocardial infarction, then number 24.0 is written. But at the same time, thrombosis is eliminated in chronic form or lasting more than 28 days. For Dressler syndrome, the number 24.1 is used. The remaining forms of acute ischemic heart disease are written at number 24.8, and if the disease is not fully refined, then the cipher is used 24.9.

For chronic form of ischemic disease, I25 code is used. If the patient has an atherosclerotic disease of the heart and blood vessels, then number 25.0 is written. Unless atherosclerosis of the heart, then 25.1. If myocardial infarction has been moved in the past, then number 25.2 is written. For cardiac aneurysm, cipher 25.3 is used. If the patient has an aneurysm of a coronary arterial vessel, then number 25.4 is indicated. However, the congenital form of this ailion is excluded. If the patient has a cardiomyopathy ischemic type, then number 25.5 is used. When ischemia proceeds without visible symptoms, a diagnosis is made with a code 25.6. The remaining forms of ischemic heart disease with chronic flow Sign up number 25.8, and if the patient's condition is not specified, the cipher 25.9 is used.

Existing varieties of illness

Angina is a variety of heart disease. This ailment is considered specific, so it can be determined by some features. Pathology develops due to the fact that the influx of blood to the heart is reduced, since the coronary arteries are narrowed. Depending on how much this process is disturbed, various forms of illness are distinguished.

If the patient has a heart muscle tissue gradually destroyed, it is necrosis. In this case, there may be a common, transmural or superficial infarction. If myocardia is not destroyed, then such a condition is called ischemia. It is distinguished by angina stress and rest. For the first form, the occurrence of severe physical exertion is characterized. This includes unstable and stable shapes of angina. As for the root angina, it occurs even without physical exertion. There are 2 main subspecies - vasospadic angina and printela.

Stenzardia itself happens:

1. 1. Voltages. It is characterized by the appearance of grain pain in the progressed area, when a person has intense physical exertion. Pain can give to the left chest, left, Blank area, neck. As soon as such unpleasant feelings appear, it is necessary to stop any loads. After some time, pain syndrome will independently pass. Additionally, you can accept nitrates. If the pathological condition does not pass, then the stroke angina is stable.
2. 2. rest. The painful sinker appears when a person is at rest. This happens in two cases. First, if the reflexor spasms a coronary vessel. This is the cause of ischemic disease. Secondly, it is necessary to take into account the walls of the printela. This is a special kind that arises sharply due to the fact that the enlighitives of the coronary arteries are overlapped. For example, this is due to the broken plaques.
3. 3. Unstable. Such a term is denoted by either angina voltage, which is gradually progressing, or a pea angina, which is a variable. If the pain syndrome fails to stop the reception of nitrates, the pathological process can no longer be monitored, and this is very dangerous.

Causes and treatment of pathology

For such pathologies, the following common symptoms are characterized:

• feeling of suturing behind the sternum and in the left side of the chest;
• the course of the disease is manifested by attacks;
• unpleasant symptoms occur sharply, and not only at physical exertion, but also at rest;
• the attack lasts usually half an hour, and if more, then this is already a heart attack;
• eliminates symptoms of nitroglycerin attack or other similar means based on nitrates.

The key point in the development of ischemic heart disease is the narrowing of the lumen in the coronary arteries.

Diseases of the cardiovascular system are recognized by leaders among the causes of death of people around the world.

One of the most dangerous pathologies, non-cure - post-infarction cardiosclerosis - the inevitable consequence of myocardial infarction. Without the necessary treatment, the disease leads to a complete cessation of cardiac activity.

- Acute stage, provoked by the insufficiency of blood flow. If blood is not delivered to any separation of the organ for more than 15 minutes, it decesses, forming a necrotic region.

Gradually, dead fabrics are replaced by connecting - this is the sclerotization process, which determines what post-infarction cardiosclerosis is. It is diagnosed after a heart attack in 100% of patients.

Connecting fibers cannot shrink and carry out electripls. The loss of the functionality of the myocardial sites causes a decrease in the percentage of blood emissions, violates the conductivity of the organ, the rhythm of heartbeat.

The diagnosis of "cardiosclerosis" is set on average three months after the heart attack.By this time the scarring process is completed, which makes it possible to determine the severity of the disease and the area of \u200b\u200bsclerotization. For this parameter, the disease is divided into two types:

1. The large-scale post-infarction cardiosclerosis is most dangerous. In this case, significant myocardial areas are subjected to scarring, it can be sclerotized completely one of the walls.
2. The fine-grade form is a small intepair of the connecting fibers, in the form of thin whiten strips. They are single, or evenly distributed in myocardium. This type of cardiosclerosis arises due to hypoxia (oxygen starvation) of cells.

After a heart attack, the fine-food form of cardiosclerosis arises very rarely. Extensive articles of heart tissues are exposed more often, or an initially small amount of scar tissue is growing as a result of late treatment. Stop sclerosation can only be done using competent diagnosis and therapy.

Code of ICD 10

In ICD 10 of such a diagnosis, as "cardiosclerosis post-infarction" is not provided, since it is impossible to name in the full sense. Instead, they use codes of other diseases that are manifested against the background of myocardial sclerotization: post-infarction syndrome, heart rate disorders and so on.

Can there be a cause of death?

The risk of sudden clinical death for people with this diagnosis is quite large. The forecast is made on the basis of information about the degree of nestness of the pathology and location of its foci. The life-threatening condition occurs when the blood flow is less than 80% of the norm, the sclerotation is subject to the left ventricle.

When the disease reaches this stage, a heart transplant is required. Without surgery, even with supporting medication therapy, the survival forecast does not exceed five years.

In addition, when post-infarction cardiosclerosis, the cause of death becomes:

• rascommunication of ventricular cuts ();
• cardiogenic shock;
• gap aneurysm;
• termination of the bioelectric conductivity of the heart (asistolia).

To avoid irreversible consequences, the patient after the suffered infarction needs to be carefully monitored for the body's reactions. At the first signs of exacerbation, immediately visiting the cardiologist.

Signs

While the sclerotic processes are subjected to minor portions of myocardium, the disease does not exhibit in any way, since at the initial stage of the disease, the heart walls retain elasticity, the muscle does not weaken. As the sclerosis area increases, the pathology becomes more noticeable. If the changes are subjected to a greater extent of the left ventricle, the patient has:

• increased fatigue;
• increasing the pulse rate;
• cough, more often dry, but it is possible to separate foam sputum;

For the left-chelted post-infarction cardiosclerosis, the formation of the so-called cardiac asthma is characterized by severe shortness of breath at night, causing the attacks of choking. She forces the patient to sit down. In the vertical position, the breathing is normalized on average after 10-15 minutes, when returning to a horizontal position, the attack may repeat.

If the scarring is exposed to the right ventricle, such symptoms appear as:

• lip and limb's bias;
• swelling and ripple veins on the neck;
• increasing in the evening; Start from stop, gradually rise, reaching a groin;
• soreness in the right side caused by the increase in liver;
• the accumulation of water in the peritoneum (swelling for a large circulation of blood circulation).

Arrhythmia is characteristic of scarring any localization, even when small parts of myocardium are amazed.

ATTENTION: Heavy shape cardiosclerosis causes dizziness and fainting. These symptoms talk about brain hypoxia.

The earlier the pathology was found, the more favorable the therapeutic forecast. The specialist will be able to see the initial stage of post-infarction cardiosclerosis on the ECG.

Symptoms for post-infarction cardiosclerosis

On ECG

Electrocardiography data have a large diagnostic value in the analysis of SCC diseases.

Signs of post-infarction cardiosclerosis on ECG are:

• myocardial changes;
• the presence of a q (in the normal value of their value is negative), almost always indicates a violation of the functionality of the blood vessels, especially when the Connech Q reaches a quarter of the height of R;
• tusk T is poorly expressed or has negative indicators;
• blockade of a feet of a beam of Gis;
• increased left ventricle;
• heartbeat failures.

When the ECG results in a static position do not go beyond the limits of regulatory, and the symptoms are manifested periodically, allowing you to assume a sclerotic process, tests with exercise or halter monitoring (24-hour study of the heart work in the dynamics can be assigned.

Cardiogram decoding should be engaged in a qualified specialist who will determine according to the graphic picture clinical picture Diseases, localization of pathological foci. To clarify the diagnosis, other methods of laboratory diagnostics can be applied.

Diagnostic procedures

In addition to the collection of anamnesis and ECG, the diagnosis of post-infarction cardiosclerosis includes the following laboratory studies:

• echocardiography is carried out to detect (or exception) chronic aneurysm, estimates of the size and condition of the chambers, as well as the walls of the heart, helps to identify abbreviations;
• ventriakulography analyzes the work of the mitral valve, the percentage of emissions, the degree of coldness;
• Ultrasound of the heart;
• x-ray shows an increase in the shade of the heart (more often on the left);
• scintigraphy using radioactive isotopes (with the introduction of the composition, these elements do not penetrate into pathological cells) allows separating damaged areas of the organ from healthy;
• PET reveals stable areas with weak blood microcirculation;
• coronaryography allows you to evaluate the coronary blood supply.

The volume and number of diagnostic procedures defines a cardiologist. Based on the analysis of the obtained data, adequate treatment is prescribed.

Unified technique (or set of means) to restore damaged myocardium. With post-infarction cardiosclerosis clinical recommendations Aimes on:

• slowdown in the development of heart failure;
• stabilization of the pulse;
• stop the scarring;
• minimizing the probability of re-infarction.

It is possible to solve the tasks exclusively with an integrated approach. The patient is necessary:

• observe the day of the day;
• limit load;
• quit smoking
• not allow stress;
• stop drinking alcoholic beverages.

Dietherapy plays a major role in the treatment of post-infarction cardiosclerosis. Six-colored meals are recommended by small portions. Preference is worth sending "easy" food with a large content of magnesium, potassium, vitamins and trace elements.

It is necessary to minimize the use of products provoking the excitation of nervous and cardiovascular systems, as well as amplifying gas formation. It:

• coffee;
• legumes;
• cocoa;
• radish;
• strong tea;
• garlic;
• cabbage.

The daily consumption of the cook salt should not exceed 3 g.

To avoid the formation of new cholesterol plaques, worsening vessels, completely refuse fried dishes, smoked spices, spices, sugar. Limit - fatty products.

Conservative treatment

Since damaged tissues are not subject to recovery, the treatment of post-infarction cardiosclerosis is aimed at blocking the symptoms and prevention of complications.

In conservative therapy, drugs apply the following pharmaceutical groups:

• aCE (,) inhibitors, slow down the scarring, reduce blood pressure, reduce the load on the heart;
• anticoagulants reduce the risk of thrombosis; This group includes: aspirin, cardiomagnet, etc.;
• diuretics prevent the fluid delay in the body cavities; The most common is: furosemid, indapamide, hydrochlorostiazide, etc. (with prolonged reception, laboratory control of the electrolyte balance in the blood is needed);
• nitrates (Nitrosorbide, Montolong, Isosorbide Mononitrate) reduce the load on the vascular system of a small circle of blood circulation;
• drugs of metabolic action (inosine, potassium preparations);
• beta-adrenobloclars (, atenolol, metoprolol) prevent the formation of arrhythmias, reduce the pulse, increase the percentage of blood emissions in the aorta;
• statins are recommended for cholesterol correction in the body;
• antioxidants (riboxin, creatinophosphate) contribute to the saturation of the tissues of the heart of oxygen, improve the exchange processes.

Attention: the names of the drugs are given for information purposes. Take any pharmaceutical funds without appointing a doctor unacceptable!

If drug treatment does not give results, the patient shows surgical intervention.

Revascularization operations (AKS, etc.)

With the defeat of the extensive area of \u200b\u200bmyocardium, only a heart transplantation can significantly help. It is resorted to this fundamental extent when all other techniques have not brought a positive result. In other situations, manipulations related to palliative surgery are carried out.

One of the most common interventions is an aortocortonary shunting. The surgeon expands the blood vessels of myocardium, which allows to improve blood flow, suspend the distribution of sclerotized areas.

If necessary, the operation of the ACH with post-infarction cardiosclerosis is carried out simultaneously with resection of the aneurysm and strengthening the weakening sections of the heart wall.

When the patient has a history of complex forms of arrhythmia, the installation of the pacemaker is shown. These devices at the expense of a stronger pulse suppress the discharge of the sinus node than reduce the likelihood of a heart stop.

Operational intervention is not a panacea, after it requires further adherence to all medical recommendations.

Necessity and limits of the exercise

LFC with post-infarction cardiosclerosis is prescribed with great care. In particularly severe cases, the patient shows a strict bed regime. If physical exertion is permissible, physiotherapy It will help stabilize the state, avoiding myocardial overload.

ATTENTION: Sports at cardiosclerosis are prohibited!

Cardiologists lean to the fact that it is necessary to gradually introduce a weak load as early as possible. After a heart attack, the patient first is located on inpatient treatment. During this period you need to restore motor functions. Usually, slow walks are practiced. It is necessary to take place at a time not more than a kilometer, stepwise increasing the number of approaches to three.

If the body is withstanding workouts, add light gymnastic exercises to restore the usual skills, preventing hypokinetic disorders, the formation of "bypass" paths in myocardium.

After the transition to the outpatient treatment, the first time should be attended by exercise of the LFC in a medical facility, where they pass under the close control of the specialist. Later, classes need to continue independently. Surprise walks are suitable as a daily load. Exercises on lifting weights need to be excluded.

Physiotherapy

In the morning, it is good to perform the following set of exercises:

1. Stand straight, put on the lower back. On the breath to dissolve them to the sides, in exhalation - return to the original position.
2. Without changing the postures, perform slopes to the sides.
3. Training brushes with an expander.
4. From the position of "standing", to inhale raising hands up, on the exhale to make a tilt forward.
5. Sitting on a chair, bending legs in the knees, then pull forward.
6. Capture hands above your head in the "Castle", perform the rotation of the body.
7. Going around the room (in place) 30 seconds, then take a break and take another.

All exercises perform 3-5 times, keeping smooth breathing. Gymnastics should not take more than 20 minutes. The pulse should be monitored - its limit increase after the load should not exceed 10% compared with the initial value.

Contraindications to therapeutic physical education:

• heart failure in acute form;
• probability of re-infarction;
• pleural swelling;
• complex forms of arrhythmias.

Select a complex of exercises and evaluate the possibility of their implementation should physiotherapist.

Effects

The patient with the diagnosis under consideration needs a lifelong medical control. Knowing what post-infarction cardiosclerosis is impossible to leave the situation without attention, as this leads to inevitable complications in the form of the following consequences:

• tamponade Pericarda;
• thromboembolia;
• blockades;
• pulmonary edema;
• reducing the automatic sinus-atrial node.

These processes negatively affect the quality of human life. The patient loses tolerance for the physical load, is deprived of the opportunity to work, lead the usual life. The launched cardiosclerosis provokes the appearance of aneurysm, the discontinuity of which leads to the death of 90% of non-period patients.

Useful video

Useful information about post-infarction cardiosclerosis can be found from the following video:

conclusions

1. Cardiosclerosis is one of the most serious heart pathologies.
2. Full cure is impossible, but supporting therapy will help extend life for many years.
3. The complex of rehabilitation measures after myocardial infarction includes: drug, sanatorium treatment, control diagnostic procedures, treatment physical education, diet and therapy.
4. Do not try to be treated independently! Reception of any medicinal preparations Or folk remedies without diagnosis and professional assessment of health status may result in serious complications and death.

IHD is the most common disease in the world, which is called, "the disease of the century". Today there are no such methods that can turn the development of IBS back. Full cure is also impossible. But with timely and systematic treatment, the development of the disease can be slowed down a little, and increase the life expectancy is also possible.

What is ischemic heart disease?

IHD is acute, or chronic heart dysfunction. It occurs due to the insufficient intake of nutrients from coronary arteries Directly to the heart muscle. The main reason is atherosclerosis, plaques are formed, which, over time, narrow the clearance in the arteries.

The bloodstream is reduced, the balance between: The needs and capabilities of the heart supply him the need for life.

The CHD is included in the CC code 10. This is International Classification Some diseases 10 revising. The ICD-10 includes 21th grade of diseases, among which there are IBS. IBS code: I20-I25.

Classification

Acute:

• unforeseen coronary death of the patient;
• acute heart attack;
• angina (vasospadic, variant);
• angina (unstable).

Chronic:

• stressful angina (indicates the functionality of the class and rest);
• post-infarction cardiosclerosis violated heartbeat and its conductivity;
• aneurysm;
• cheerful ischemia.

Symptoms

Mental symptoms:

1. panic, almost animal fear;
2. inexplicable apathy;
3. unfortunate concern.

Diagnostics

The purpose of the diagnosis:

1. find existing risk factors: not diagnosed earlier diabetes, bad cholesterol, kidney disease, etc.;
2. according to the results of the diagnosis, the state of the heart muscle and arteries should evaluate;
3. pick up the right treatment;
4. understand whether the operation will need, or you can still conduct conservative treatment.

First you need consultation of a cardiologist. If the operation is shown then you need a cardiac surgeon. With elevated sugar, the treatment is initially conducted - an endocrinologist.

Blood tests are prescribed:

• common;
• blood on sugar;
• general lipid profile;
• urea, creatine (evaluates kidney performance).

Urine tests:

• microalbuminuria (Mau) - for the presence of protein: called albumin.
• proteinuria - determines the health of the kidneys.

Other diagnostics:

• blood measurement;
• radiography;
• ECG without load;
• ECG with load;
• determining the level of harmful cholesterol in the blood;
• Echo kg - ultrasound of the heart;
• coronoangiography.

When diagnosing, it is necessary to take into account the forms of the IBS, their five:

1. Stress angina.
2. Vasospadic angina.
3. Myocardial infarction.
4. Post-infarction cardiosclerosis.
5. Heart failure.

The reasons

There are two reasons:

1. Called the disease - "heat". This is when the liver has sharply produces cholesterol. This is the imbalance of the regulating system MHRIS-PA.
2. This disease is "cold", associated with digestion. With anomalous slowing down and impairment fat Exchange There is an imbalance of the control system of the Bad Kan.

Excess blood cholesterol accumulates in the vascular walls in the form of atherosclerotic plaques. Gradually lumen in the vessels narrows, normal blood circulation due to this can not be, so the blood supply to the heart deteriorates.

Development mechanism

• Heart, as you know, pumped blood, but it also is in dire need of good blood supply, it means that in nutrients and the delivery of oxygen.
• Card muscle feeds bloodcoming from two arteries. They go from the root of aorta and envelm heart in the form of a crown. Therefore, they have such a name - coronary vessels.
• Then arteries are divided into several branches, smaller. And each of them should feed only its portion of the heart.

  If the lumen even one vessel is slightly narrowed, the muscle will begin to experience a shortage of nutrition. But if it is completely blocked, then inevitably the development of many serious diseases.

• Initially, with intensive load Man will experience a small pain behind the sternum - this is called threw stress. But the muscle metabolism will eventually deteriorate over time, the lumens of the arteries narrow. Therefore, pain now will appear more often: with a slight load, then in horizontal position Body.
• Together with the stress angina Along the way, it may be formed chronic heart failure. It manifests itself shortness of breath, strong edema. If there is a sudden gap of the plaque, he will entrust the overlap of the remaining glorification of the artery, then myocardial infarctioninevitable.
  He can lead to a heart stop And even death, if not to give a person emergency. The severity of the lesion will depend only on where the blockage occurred. In the artery or its branching, and which one. What it is larger, the more serious the consequences for a person will be.
• For the development of heart attack The clearance must narrow no less than 70%. If it is gradually happening, then the heart can still adapt to a decrease in blood volume. But sharp blockage is very dangerous, it often leads to the death of the patient.

Risk factors

Treatment

There are many methods for the treatment of this serious illness. Proper treatment will allow not only to improve the quality of life, but even significantly extend it.

Treatment methods:

1. conservative - lifelong reception of drugs, therapeutic physical education is shown, healthy nutrition, bad habits are completely unacceptable now, it is desirable to lead only healthy image Life.
2. surgical - Restores vessels.

Conservative treatment

A significant role will play: Reducing the use animal fats, in the diet should be present only healthy foods, good leisure hiking.

So, the affected myocardia will be able to adapt to the functional possibilities of vessels supplying myocardium blood.

Medical therapy - Appointment of anti-inanal drugs. They warn or completely remove the attacks of angina. But often conservative treatment is not always effective, then surgical correction methods are used.

Surgery

The treatment is selected depending on the degree of damage to coronary vessels:

1. Aorticorial shunting - Take a vessel (artery, vein) in the patient and are stitched to the coronary artery. Create thus bypassing the blood supply path. Blood is now in sufficient volume will flow into myocardium, eliminating the ischemia and attacks of angina.
2. - In the affected vessel, a tube (stent) is introduced, which from now on to prevent the further narrowing of the vessel. The patient after installing the stent will have to pass, long-term antiagregative therapy. In the first two years, control coronorography is shown.

In severe cases, they can offer Transmocardial Miocardial Laser Revascularization. A laser guides the affected area of \u200b\u200bthe surgeon, creating a set of additional channels less than 1 ml. Channels, in turn, will contribute to the growth of new blood vessels. This operation is made separately, but you can combine with aort of coronary shunting.

Medications

Medicines must only be prescribed by the doctor.

Their arsenal is large enough, and often the reception of several drugs of different groups is required:

• nitrate - This is all known nitroglycerin, it not only expands coronary artery, but also blood delivery to myocardium will significantly improve. Used in non-interpimable pain, preventing attacks;
• antiagreganta - for the prevention of thrombosis, dissolution of thromboms: cardiomagnet, heparin, Laspirin, etc.;
• beta adrenoblocators - The need for oxygen is reduced, normalize rhythm, endowed with antiagregative actions: Vero-Atenolol metoprolol, Atenolol-UFFI, Atenolol, etc.;
• calcium antagonists - Have wide spectrum Actions: hypotensive, anti-naiginal, is improved tolerability to low physical exertion: nifedipine, isoptin, verapamil, verascard, verapamil-luct, etc.;
• fibrats and statins - Lower cholesterol in the blood: Simvastatin, Lovastatin, Rosavastatin, etc.;
• preparations that improve metabolism In the heart muscle - inosine-esk, riboxin, inosie-ф, etc.

Folk remedies

Before treatment must be consulted with their attending physician.

Folk remedies:

The most popular recipes:

1. 1 tbsp. l. flat fruit hawthorn;
2. 400 ml of boiling water.

For the night of the thermos, fall asleep fruit, pour boiling water. Let it insist until the morning. Drink 3-4 times a day 30 ml before meals for 1 hour. Reception 1 month, then take a break for a month and can be repeated.

1. hawthorn crush;
2. herb of dyeing.

Mix in equal proportions: take 5-6 tbsp. l. And pour 1.5 liters of boiling water, wrap and let it be imagined until warm. Take 0.5 glasses 2-4 times a day preferably before meals, half an hour.

1. leaves of white mistletoe - 1 tbsp. l.;
2. buckwheat flowers - 1 tbsp. l.

Pour 500 ml of boiling water and insist 9-10 hours. Drink 2-4 st. l. 3-5 times a day.

1. horsetail field - 20 gr.;
2. hawthorn flowers - 20 gr.;
3. herb of a bird of the bird - 10 gr.

Pour 250 ml of boiling water, to insist about an hour be sure to strain. To drink with small sips during the day you can take every week.

1. corn root - 40 gr.;
2. medicine Lovers - 30 grams.

Pour boiling water (covered with water) and cook for 5-10 minutes, insisted within an hour. Take 1/4 Art. 2-3 times a day necessarily after eating.

Modern methods of treatment

• Treatment methods are improvedBut the principle of treatment remains the same - this is the restoration of blood flow.
  This is reached in 2 ways: Medical, surgical. Medical therapy is the basic base of treatment, especially for chronic IBS.
• Treatment prevents the development of some serious forms of IBS: Sudden death, heart attack, unstable angina. Cardiologists are used various drugs: Reduced "bad" cholesterol, antiarrhythmic, thinning blood and so on.
  In severe cases, surgical methods are used:
  • Most modern method Treatment - this is endovascular Surgery. This is the newest direction in medicine, allowing to replace surgical interference with bloodless without cuts. They are less painful, never cause complications.
    Operation is carried out without cuts, catheter and other tools are injected through small punctures on the skin and are carried out under the control of radiation visualization methods. Such an operation is performed outpatient, even anesthesia in most cases do not apply.

Complications and consequences

The complications include:

• formation of focal cardiosclerosis and diffuse atherosclerotic cardiosclerosis - there is a decrease in functioning cardiomyocytes. In their place, coarse connecting tissue is formed (scar);
• "Sleeping" or "stunned" myocardium - the reduction of the left ventricle is disturbed;
• a diastolic, systolic function is broken;
• other functions are also violated: automatism, excitability, reduction, etc.;
• infliction - cardiomyocytes (energy metabolism of myocardial cells).

Effects:

1. According to statistics, 1/4 of death occurs precisely because of the ischemic heart disease.
2. Often diagnosed consequences - diffuse cardiosclerosis, post-infarctional flow. The junction tissue, raging, is replaced by the pathogenic fibrous scar with the valve strain.
3. Myocardine hibernation is an adaptive reaction. The heart tries to adapt under the existing blood supply, is challenged under the current blood flow.
4. Angina - begins with insufficient coronary blood circulation.
5. Diastolic, or systolic left-detection dysfunction - the reduction capacity of the left ventricle is broken. Or it is normal, but the ratio between: the filling of diastole and atrial systole is broken.
6. Conductivity and arrhythmia developed - initiating myocardial reductions incorrectly function.
7. Heart failure precedes: myocardial infarction.

The most dangerous types of IHS and angina stress, wearing spontaneous character, they can instantly disappear and occur again. Can transform into a heart attack or simply copied.

Diagnosis IBS - This is not a sentence, but the occasion does not fall in spirit. It is necessary to act and do not miss precious time, and choose the optimal therapeutic tactics. In this you will help the cardiologist. It will not only save you life, but also will help preserve activity for many years. Health to all and longevity!

Aorto-coronary shunting and stenting - One of the main reasons for the development of diseases of the cardiovascular system is atherosclerosis of coronary vessels, as a result of which plaques are formed in vessels that make blood circulation. Next develops ischemia of the heart muscle: ... ... ... Encyclopedia Newsmakers

Heart and lungs from Gray's Anatomy, 1918 ... Wikipedia

Heart and Light of Gray's Anatomy, 1918 Operation of Aorticoronary Shunting Coronary Shunting, Aorticorona Shunting (AKS) Operation, allowing you to restore blood flow in the arteries of the heart by bypassing the place of narrowing of the coronary vessel ... Wikipedia

Request "IBS" is redirected here. See also IBS (river) Ischemic heart disease MKB 10 i20. I25. ICD 9 ... Wikipedia

Cardiac failure - Honey. Heart failure (CH) impairment of the ability of the heart to maintain the bloodaryness required for the metabolic needs of the body, without the participation of additional compensatory mechanisms. Classification by origin ... ... Handbook of Diseases

Operational reception of the surgery period, which consists in performing its main task (diagnosis of the disease, treatment). The names of the operations are formed from the names of operational techniques. There are the following operational techniques: ectomia ... ... Wikipedia

The period of the surgical operation consisting in performing its main task (diagnosis of the disease, treatment). The names of the operations are formed from the names of operational techniques. There are the following operational techniques: ectomia removal of the organ; Tomia ... Wikipedia

RCRZ (Republican Center for Health Development MD RK)
Version: Clinical Protocols MOR RK - 2013

Other forms of angina (I20.8)

Cardiology

general information

Short description

Approved by the Protocol
Expert Commission on Health Development
from June 28, 2013

IBS- This is a sharp or chronic heart damage caused by a decrease in or stopping blood delivery to myocardium due to the painful process in coronary vessels (WHO determination of 1959).

Angina - this is clinical syndromemanifested by a feeling of discomfort or pain in the chest compressive, gulling character, which is localized most often behind the sternum and can irradiating into the left hand, neck, low jaw, epigastric area. The pain is provoked by physical activity, reaching cold, abundant meal, emotional stress; It takes place alone or eliminated by nitroglycerin sublingual for a few seconds or minutes.

I. Introductory part

Name: IHS stable angina stress
Protocol code:

MKB-10 codes:
I20.8 - other forms of angina

Abbreviations used in the protocol:
AG - arterial hypertension
AA - Antianginal (therapy)
Hell - blood pressure
AKSH - Aorto-Coronary Shunting
Alt - Alaninaotransferase
AO - Abdominal Obesity
Act - Aspartataminotransferase
BKK - calcium channel blockers
VB - general practitioners
VPN - upper borderline
VPU - Wolf Parkinson-White Syndrome
GKMP - Hypertrophic Cardiomyopathy
GLL - left ventricular hypertrophy
Dad - diastolic blood pressure
DLP - Dyslipidemia
HE - ventricular extrasystole
IBS - ischemic disease hearts
BMI - body mass index
IKD - Insulin short action
KAG - Coronoanhibition
Ka - coronary arteries
KFK - Creatynphosfokineza
MS - metabolic syndrome.
NTG - violation of glucose tolerance
NWIA - Continuous intravenous insulin therapy
OSH - common cholesterol
OKS BPST - sharp coronary syndrome Without lifting seg cop St.
OX CPST - acute coronary syndrome with the lifting of the ST segment
From - Waist
Garden - systolic blood pressure
SD - Sugar Diabetes
SCF - Speed \u200b\u200bof glomerular filtration
Smad - daily monitoring arterial pressure
TG - triglycerides
Tim - the thickness of the intima-media complex
TTG - Testing Tolerance to Glucose
U3DG - Ultrasound Doppler
Fa - physical activity
FC - functional class
FN - Physical Load
FR - Risk Factors
COPD - chronic obstructive pulmonary disease
CHF - chronic heart failure
HS LVP - High Density Lipoprotein Cholesterol
XS LNP - low density lipoprotein cholesterol
4kb - percutaneous coronary intervention
Heart rate - cardiac frequency
ECG - electrocardiography
Ex-electrocardiomulator
EchoCG - Echocardiography
VE - minute volume of breathing
VCO2 - the amount of carbon dioxide allocated per unit of time;
RER (respiratory factor) - the ratio of VCO2 / VO2;
Br - respiratory reserve.
BMS - stent without medicinal coverage
DES - medicinal coating stent

Protocol development date: year 2013.
Patient category: Adult patients who are inpatient treatment with a diagnosis of IBS stable angina stress.
Protocol users:doctors therapists, cardiologists, interventional cardiologists, cardiac surgers.

Classification

Clinical classification

Table 1. Classification of gravity of stable angina stress according to the classification of the Canadian Association of Cardiologists (Campeau L, 1976)

Diagnostics

II. Methods, approaches and diagnostic and treatment procedures

Laboratory tests:
1. Oak
2. OAM
3. blood sugar
4. Creatine blood
5. Common protein
6. ALT.
7. Blood electrolytes
8. Lipid Blood Spectrum
9. Coagulogram
10. ELISA for HIV (before kAg)
11. IFA on markers viral hepatitis (before kAg)
12. I / g ball
13. Blood on microreaction.

Instrumental examinations:
1. ECG
2. Ehoche
3. FG / radiography OGK
4. EFGDS (by indication)
5. ECG with load (VEM, Tredmil test)
6. Stress Echocrine (by testimony)
7. Daily monitoring of ECG on Holter (by testimony)
8. Coronoanhibition

Diagnostic criteria

Complaints and anamnesis
The main symptom of stable angina is a sense of discomfort or pain in a thoracic compressive, graceful character that is localized most often behind the sternum and can irradiating into the left hand, neck, lower jaw, the epigastric area.
Basic Breast Pain Factors: Physical Load - Fast Walking, Lifting uphill or on the stairs, gravity transfer; Increased blood pressure; cold; abundant meal; Emotional stress. Usually the pain takes place alone after 3-5 minutes. or within a few seconds or minutes after sublingual nitroglycerin intake in the form of tablets or spray.

table 2 - Symptom complex angina

When collecting anamnesis, it is necessary to note the risk factors of the IBS: male floor, elderly age, dyslipidemia, ag, smoking, diabetes, increased heart rate, low physical activity, excess body weight, alcohol abuse.

The states provoking myocardial ischemia or exacerbating its current is analyzed.
enhancing oxygen consumption:
- uncommon: hyperthermia, hyperthyroidism, inxication with sympathomimetics (cocaine, etc.), excitation, arteriovenomous fistula;
- Hearts: GKMP, aortic patterns of heart, tachycardia.
reduced oxygen flow:
- Unreliable: hypoxia, anemia, hypoxemia, pneumonia, bronchial asthma, COPD, pulmonary hypertension, night apnea syndrome, hypercoagulation, polycythemia, leukemia, thrombocytosis;
- Cardiac: congenital and acquired heart defects, systolic and / or diastolic dysfunction of the left ventricle.

Physical examination
When examining the patient:
- It is necessary to estimate the body mass index (BMI) and the waist circle, to determine the heart rate, pulse parameters, hell on both hands;
- It is possible to show signs of a violation of lipid metabolism: xanthomas, xantellasma, edible closure of the corneal of the eye ("senile arc") and stenpered lesion of the main arteries (sleepy, subclavian peripheral arteries of the lower extremities, etc.);
- during the physical activity, sometimes alone, with auscultation, the 3rd or 4th heart tones may be brought, as well as systolic noise at the top of the heart, as a sign of the ischemic dysfunction of papillary muscles and mitral regurgitation;
- Pathological pulsation in the precartial region indicates the presence of the aneurysm of the heart or the expansion of the boundaries of the heart due to severe hypertrophy or myocardial dilatation.

Instrumental research

Electrocardiography In 12 leads is a mandatory method: diagnosis of myocardial ischemia during stable angina. Even in patients with severe angina, changes to the ECG are often absent, which does not exclude the diagnosis of myocardial ischemia. However, the ECGs may identify signs of coronary heart disease, for example, a myocardial infarction or impaired repolarization. ECG may be more informative if it is recorded during an attack of pain. In this case, you can reveal the shift of the ST segment under myocardial ischemia or signs of damage to pericardia. ECG registration during with stools of pain is especially shown if there is an existence of vasospasm. Other changes, such as left ventricle hypertrophy (GLL), can be detected on the ECG, the blockade of the Gis beam legs, the premature excitation syndrome of ventricles, arrhythmias or conductivity disorders.

Echocardiography: Two-dimensional and doppler echocardiography alone makes it possible to eliminate other heart diseases, for example, valve defects or hypertrophic cardiomyopathy, and explore the function of the ventricles.

Recommendations for the conduct of echocardiography in patients with stable angina
Class I:
1. Auxual changes indicating the presence of heart valves or hypertrophic cardiomyopathy (B)
2. Signs of heart failure (B)
3. Moved myocardial infarction (B)
4. Blockade of the left leg of a beam of His, Teeth Q or other significant pathological changes to ECG (C)

Daily ECG Monitoring Showing:
- for diagnosis of solemn myocardial ischemia;
- to determine the severity and duration of ischemic changes;
- To detect vasospad angina or angina printela.
- to diagnose rhythm disorders;
- To assess the variability of cardiac rhythm.

Criterion of myocardium ischemia during daily monitoring (cm) ECG is the depression of the ST\u003e 2 mm segment with its duration of at least 1 min. It has the value of the duration of ischemic changes according to CM ECG. If the total duration of the reduction in the ST segment reaches 60 minutes, then this can be regarded as a manifestation of severe CBS and is one of the testimony to revascularize myocardium.

ECG with load:Sample with load is a more sensitive and specific method of diagnosing myocardial ischemia than ECG alone.
Recommendations for conducting a sample with physical activity in patients with stable angina
Class I:
1. The sample should be carried out in the presence of angina symptoms and the average / high probability of the coronary heart disease (taking into account age, gender and clinical manifestations) Except where the sample cannot be made due to the intolerance to the load or the availability of changes to the ECG alone (B).
Class IIB:
1. The presence of depression of the segment of ST at rest ≥1 mm or the treatment with digoxin (B).
2. Low probability of the presence of coronary heart disease (less than 10%), taking into account age, gender and the nature of clinical manifestations (B).

Causes of termination of samples with a load:
1. The appearance of symptoms, for example, chest pain, fatigue, shortness of breath or intermittent chromotype.
2. The combination of symptoms (for example, pain) with pronounced changes in the ST segment.
3. Patient safety:
a) the pronounced depression of the ST segment (\u003e 2 mm; if the depression of the ST segment is 4 mm or more, this is an absolute indication to the termination of the sample);
b) the rise of the ST segment ≥2 mm;
c) the emergence of a threatening violation of rhythm;
d) a resistant reduction in systolic blood pressure by more than 10 mm Hg. st.;
d) high arterial hypertension (systolic pressure of more than 250 mm Hg. Art. or diastolic hell of more than 115 mm Hg. Art.).
4. Achieving the maximum heart rate can also serve as a basis for stopping the sample in patients with excellent portability of the load, which have no signs of fatigue (the decision takes the doctor at its discretion).
5. Failure to the patient from further research.

Table 5. - Characteristics of FC patients with IBS with stable angina, according to the results of the sample with FN (Aronov D.M., Lupanov V.P. et al. 1980, 1982).

Stress echocardiography The Load ECG is superior to a prognostic value, has a greater sensitivity (80-85%) and specificity (84-86%) in the diagnosis of IBS.

Perfusion scintigraphy myocardium With load. The method is based on a fractional principle of sapirstein, according to which radionuclide in the first circulation process is distributed in myocardium in quantities proportional to the coronary fraction heart Emissionand reflects the regional distribution of perfusion. Test with FN is a more physiological and preferred method of playing myocardial ischemia, however, pharmacological samples can be used.

Recommendations for stress echocardiography and myocardiography scintigraphy in patients with stable angina
Class I:
1. The presence of changes to the ECG alone, the blockade of the left leg of the GISE beam, the depression of the ST segment of more than 1 mm, an electrocardiographer or Wolf-Parkinson-White syndrome, which do not allow to interpret the ECG results with the load (B).
2. Non-valid ECG results with a load at an acceptable tolerance of its tolerance in a patient with a low probability of coronary heart disease, if the diagnosis causes doubt (B)
Class IIA:
1. Determination of localization of myocardial ischemia before the myocardial revascularization (percutaneous intervention in coronary arteries or anorthocormerum shunting) (B).
2. Alternative to ECG with a load in the presence of appropriate equipment, personnel and means (B).
3. An ECG alternative with a load at the low probability of the presence of coronary heart disease, for example, in women with atypical chest pain (B).
4. Evaluation of the functional value of the moderate stenosis of coronary arteries identified during angiography (C).
5. Determination of localization of myocardial ischemia when choosing a revascularization method in patients who carried out angiography (B).

Recommendations for the use of myocardium echocardiography or scintigraphy with pharmacological breakdown in patients with stable angina
Class I, IIA and IIB:
1. The above indications, if the patient cannot perform adequate load.

Multispical computed tomography of the heart and coronary vessels:
- prescribed when examining men aged 45-65 years and women at the age of 55-75 years without established CVDs with the aim of early detection of initial signs of coronary atherosclerosis;
- as an initial diagnostic test in outpatient conditions in patients aged< 65 лет с атипичными болями в грудной клетке при отсутствии установленного диагноза ИБС;
- as an additional diagnostic test in patients aged< 65 лет с сомнительными результатами нагрузочных тестов или наличием традиционных коронарных ФР при отсутствии установленного диагноза ИБС;
- for differential diagnosis Between CHHN ischemic and non-hay genesis (cardiopathy, myocardits).

Magnetic resonance tomography of the heart and blood vessels
Stress MRI can be used to identify the asylonia of the LV wall, caused by dobutin, or violations of perfusion induced by adenosine. The method is applied recently, therefore it is less studied than other non-invasive visualizing methods. The sensitivity and specificity of abnormal disorders of the LV detected using MRI is 83% and 86%, respectively, and perfusion disorders - 91% and 81%. Stress-perfusion MRI is characterized by a similar high sensitivity, but reduced specificity.

Magnetic resonance coronary angiography
MRI is characterized by a lower performance coefficient and less accuracy in the diagnosis of IWS than the MSCT.

Coronorangiography (Cat) - The main method of diagnosing the condition of the coronary direction. KAG allows you to choose an optimal method of treatment: drug or myocardial revascularization.
Indications for destination kag Patient with stable angina when solving the question of the possibility of completing chkb or ksh:
- severe angina pharmacy III-IV FC, persisting with optimal anti-inanal therapy;
- signs of expressed myocardial ischemia based on the results of non-invasive methods;
- the presence of the patient in the history of the episodes of the Sun or hazardous ventricular rhythm disorders;
- progression of the disease according to the dynamics of non-invasive tests;
- early development of heavy angina (FC III) after it and myocardial revascularization (up to 1 month);
- dubious results of non-invasive tests in persons with socially significant professions (community drivers, pilots, etc.).

Absolute contraindications for destination kAg currently do not exist.
Relative contraindications to kag:
- Ostray renal failure
- chronic renal failure (blood creatine level 160-1800 mmol / l)
- Allergic reactions to contrast substance and intolerance of iodine
- Active gastrointestinal bleeding, exacerbation peptic disease
- pronounced coagulopathy
- Heavy anemia
- acute violation of cerebral circulation
- pronounced violation mental state Patient
- Serious concomitant diseases, significantly shortening the life of the patient or sharply increasing the risk of subsequent medical interventions
- Failure of a patient from possible further treatment after the study (endovascular intervention, KSH)
- pronounced lesion of peripheral arteries, limiting arterial access
- decompensated CN or acute pulmonary swelling
- malignant AG, poorly treatable
- Cardiac glycosides intoxication
- pronounced violation of electrolyte exchange
- fever of unknown etiology and sharp infectious diseases
- Infectious endocarditis
- exacerbation of severe negrodiological chronic disease

Recommendations for chest radiography in patients with stable angina
Class I:
1. The radiography of the chest is shown in the presence of symptoms of heart failure (C).
2. The radiography of the chest is justified if there are signs of lung damage (B).

Fibrogastroduodenoscopy (FGDS) (according to indications), study on Helicobtrcter Pylori (according to indications).

Indications for consulting professionals
Endocrinologist - diagnosis and treatment of violations of glycemic status, treatment of obesity, etc., patient training Principles diet nutrition, translation to the treatment of short-acting insulin before planned surgical revascularization;
Neurologist - the presence of symptoms of brain damage (acute violations of the cerebral circulation, transient brain circulation disorders, chronic forms vascular brain pathology, etc.);
Okulist. - the presence of symptoms of retinopathy (according to indications);
Angiohurrh.- diagnosis and treatment recommendations for atherosclerotic damage to the peripheral arteries.

Laboratory diagnostics

Class I (all patients)
1. Lipid levels of an empty stomach, including total cholesterol, LDL, HDL and triglycerides (B)
2. Automobile Glycemia (B)
3. General analysis blood, including the definition of hemoglobin and leukocyte formula (IN)
4. Creatinine level (C), Creating Creatinine clearance
5. Indicators of the function of the thyroid gland (by testimony) (C)

Class IIA
Oral sample with glucose load (B)

Class IIB.
1. Highly sensitive C-jet protein (B)
2. Lipoprotein (A), Apoa and Apov (B)
3. Homocysteine \u200b\u200b(B)
4. HBALC (B)
5. NT-BNP

Table 4. - Evaluation of lipid spectrum indicators

List of basic and additional diagnostic events

Basic research
1. Common blood test
2. Definition of glucose
3. Definition of creatinine
4. Determination of creatinine clearance
5. Definition of Alt.
6. Definition of PH
7. Definition of fibrinogen
8. Determination of MHO.
9. Definition of total cholesterol
10. Determination of LDL.
11. Determination of LDP
12. Triglyceride detection
13. Determination of potassium / sodium
14. Calcium Determination
15. General urinary analysis
16.KG
17.3XOK
18.Akg-test with exercise (VEM / Tredmill)
19.stress-Ehokg

Additional research
1. Glycemic profile
2. X-ray organs of the chest
3. EFGDS
4. Glikated hemoglobin
5 .. oral sample with glucose load
6. NT-PROBNP
7. Definition of HF CRH
8. Definition of ABC.
9. Definition of AFTV
10. Definition of Magnesium
11. Definition of a common bilirubin
12. CM Hell
13. See ECG for Holter
14. Coronaryography
15. Myocardial Perfusion Scyntigria / Officon
16. Multispiral computed tomography
17. Magnetic resonance tomography
18. PET

Differential diagnosis

Differential diagnosis

Table 6 - Differential Diagnosis of Pain in Chest

The clinical picture involves the presence of three signs:
- Typical angina, arising from FN (less often - angina or shortness of breath at rest);
- the positive result of the ECG with FN or other stress tests (depression of ST on the ECG segment, defects of myocardial perfusion on scintigrams);
- Normal coronary arteries on kag.

Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

Treats of treatment:
1. Improve the forecast and prevent the occurrence of myocardial infarction and sudden death and, accordingly, increase life expectancy.
2. Reduce the frequency and reduce the intensity of angina attacks and, thus, improve the quality of the patient's life.

Tactics of treatment

Non-drug treatment:
1. Informing and patient training.

2. Failure to smoking.

3. Individual recommendations on permissible physical activity depending on the FC angina and the status of the LV function. It is recommended to perform exercise, because They lead to an increase in TFN, a decrease in symptoms and have a favorable effect on MT, levels of lipids, blood pressure, glucose tolerance and insulin sensitivity. Moderate loads of 30-60 min ≥5 days a week depending on FC angina (walking, easy run, swimming, bike, ski).

4. Recommended diet: consumption of a wide range of products; control over calorie food, to avoid obesity; an increase in the consumption of fruits and vegetables, as well as whole grain and bread, fish (especially greasy varieties), lean meat and low-fat dairy products; Replace saturated fats and trans-fats, monounsaturated and polyunsaturated fats from vegetable and sea sources, as well as reduce the total amount of fats (of which less than one third should be saturated) to less than 30% of the total calorie consumed, and reduce salt consumption , with an increase in blood pressure. The normal body mass index (BMI) is considered to be less than 25 kg / m and recommends a reduction in weight with CMT 30 kg / m 2 or more, as well as during a waist circle more than 102 cm in men or more than 88 cm in women, since weight loss can Improve many associated with obesity risk factors.

5. Unacceptable alcohol abuse.

6. Treatment of related diseases: with ag - achievement of the target level<130 и 80 мм.рт.ст., при СД - достижение количественных критериев компенсации, лечение гипо- и гипертиреоза, анемии.

7. Recommendations for sexual activity - sexual intercourse can provoke the development of angina, so nitroglycerin can be adopted before it. Phosphodiesterase inhibitors: Sildenafil (Viagra), Tadafil and Vardenafil, used to treat sexual dysfunction should not be used in combination with prolonged nitrates.

Medicia treatment
Medicinal preparations that improve the prognosis in patients with angina:
1. Antitrombocytic drugs:
- acetylsalicylic acid (dose of 75-100 mg / day - long).
- patients with intolerance to aspirin shows the use of clopidogrel 75 mg per day as an alternative to aspirin
- Double antiagregative therapy with aspirin and oral use of adf receptor antagonists (clopidogrel, ticugrelor) should be used to 12 months after 4kb, with a strict minimum for patients with BMS -1 month, patients with DES - 6 months.
- Protection of the stomach using proton pump inhibitors must be carried out for double antiagregative therapy in patients with high risk of bleeding.
- in patients with clear indications for the use of oral anticoagulants (atrial fibrillation on the CHA2DS2-VASC scale ≥2 or the presence of mechanical valve deasts), they must be used in addition to antitrombocyte therapy.

2. Hydolypidemic means lowering the level of HLNP:
- Statins. The most studied statins with CHD atorvastatin 10-40 mg and rosevastatin 5-40 mg. Again the dose of any of the statins should follow the interval in 2-3 weeks, since for this period the optimal effect of the drug is achieved. The target level is determined by the HLPNP - less than 1.8 mmol / l. Control of indicators in the treatment of statins:
- It is necessary to initiate blood test on the lipid profile, Act, Alt, KFK.
- After 4-6 weeks of treatment, we should estimate the tolerability and safety of treatment (patient complaints, repeated blood test on lipids, Act, Alt, KFK).
- When titration, the dose is primarily focused on the tolerance and safety of treatment, in the second - to achieve target lipid levels.
- With an increase in the activity of the liver transamamine more than 3rd, it is necessary to repeat the blood test again. It is necessary to exclude other causes of hyperfermenia: alcohol intake on the eve of, cholelyatiasis, aggravation of chronic hepatitis or other primary and secondary liver diseases. The reason for increasing the activity of KFK can serve damage to the skeletal muscles: intense physical exertion on the eve, intramuscular injection, polyimiositis, muscle dystrophy, injuries, operations, myocardial lesions (im, myocarditis), hypothyroidism, HSN.
- With Act indicators, Alt\u003e 3 VPN, KFK\u003e 5 VPN Statins are canceled.
- Inhibitor of the intestinal absorption of cholesterol - Ezetimib 5-10 mg 1 time per day - inhibits the absorption of food and biliary xs in the epithelium of the small intestine.

Indications for the appointment of Ezetimiba:
- in the form of monotherapy for the treatment of patients with a heterozygous Form of SGHS, which do not tolerate statins;
- In combination with statins in patients with a heterozygous form of the SGHS, if the level of hs-LPP remains high (more than 2.5 mmol / l) against the background of the highest possible doses of statins (simvastatin 80 mg / day, atorvastatin 80 mg / day) or a bad one is noted. Portability of high doses of statins. Fixed combination - Inceni preparation, which contains - Ezetimib 10 mg and symbastatin 20 mg in one tablet.

3. β-adrenoblocators
The positive effects of the use of this group of preparations are based on a decrease in the need of myocardium in oxygen. Bl-selective blockers include: Atenolol, metoprolol, bisoprolol, nebivolol, to non-selective - propranolol, supolyol, carvedilol.
β - blockers should be preferred in patients with IHCs at: 1) the presence of heart failure or left ventricular dysfunction; 2) accompanying arterial hypertension; 3) reductantaricular or ventricular arrhythmia; 4) transferred myocardial infarction; 5) the presence of a clear connection between the physical activity and the development of the attack of angina
On the effect of these drugs, with a stable angina, it is possible to calculate only if they reach a distinct blockade of β-adrenoreceptors. To do this, it is necessary to support heart rate of rest within 55-60 UD / min. In patients with more pronounced angina, it is possible to reduce the heart rate of up to 50 ice / min, provided that such bradycardia does not cause unpleasant sensations and does not develop AV blockaga.
Metoprolol Succinate 12.5 mg twice a day, if necessary, increasing the dose to 100-200 mg per day at twofold use.
Bisoprolol - Starting with a dose of 2.5 mg (with the existing CHF decompensation - with 1.25 mg) and, if necessary, increasing to 10 mg, in one-time appointment.
Carvedilol is a starting dose of 6.25 mg (with hypotension and symptoms of HSN 3,125 mg) in the morning and in the evening with a gradual increase of up to 25 mg twice.
Nebivolol - Starting with a dose of 2.5 mg (with the available CHHN decompensation - with 1.25 mg) and, if necessary, increasing to 10 mg, once a day.

Absolute contraindications To the appointment of beta-blockers with IHD - pronounced bradycardia (CSS less than 48-50 per minute), an atrioventricular blockade of 2-3 degrees, a sinus node weak syndrome.

Relative contraindications - bronchial asthma, COPD, acute heart failure, pronounced depressive conditions, peripheral vessel diseases.

4. ACE inhibitors or Ara II
The IAPF is prescribed to patients with IBS in the presence of signs of heart failure, arterial hypertension, diabetes and the absence of absolute contraindications to their intended purpose. Preparations are used with a proven effect on a long-term forecast (Ramipril 2.5-10 mg once a day, perindopril 5-10 mg once a day, fozinopril 10-20 mg per day, zofenopril 5-10 mg, etc.). In case of intolerance of the IAPF, angiotensin II receptor antagonists can be assigned with a proven positive effect on a long-term forecast for IHD (Valsartan 80-160 mg).

5. Calcium antagonists (calcium channel blockers).
Are not fundamental means in the treatment of IBS. Can eliminate the symptoms of angina. The effect on the survival and frequency of complications, in contrast to beta-blockers, is not proved. Prescribed in contraindications to the purpose of the B-blockers or their insufficient effectiveness in combination with them (with dihydropyridines, except for short-range nifedipine). Another indication is vasospast angina.
Currently, for the treatment of stable angina, it is recommended mainly BKK for a long-term action (amlodipine); They are used as the preparations of the second row, if the symptoms are not eliminated by B-blockers and nitrates. BKK should be preferred with associated: 1) obstructive pulmonary diseases; 2) sinus bradycardia and pronounced irregularities of atrioventricular conductivity; 3) variant angina (printelastyle).

6. Combined therapy (fixed combinations) Patients with stable angina of II-IV FC are carried out according to the following testimony: the impossibility of selecting effective monotherapy; the need to enhance the effect of monotherapy (for example, during the period of increased physical activity of the patient); correction of adverse hemodynamic shifts (for example, tachycardia caused by BKK of dihydropyridine groups or nitrates); with a combination of angina with hypertension or violations of heart rhythm, which are not compensated in cases of monotherapy; In case of intolerance to the patients of generally accepted doses of drugs during monotherapy (at the same time, in order to achieve the necessary AA effect, it is possible to combine small doses of drugs, adding to the main aa drugs are sometimes assigned to other funds (activators of potassium channels, ACE inhibitors, antitrombocyters).
When conducting AA therapy, it should strive to almost complete the elimination of anginal pain and the return of the patient to normal activity. However, therapeutic tactics are not in all patients gives the necessary effect. Part of patients with exacerbation of IBS sometimes there is an aggravation of the severity of the state. In these cases, consultation of cardiac surgery is necessary to possibly provide patient cardiac surgical care.

Putting and prevention of anginal pain:
Angianginal therapy solves symptomatic tasksin restoring the balance between the need and delivery of oxygen to myocardium.

Nitrates and nitrate-like. In the development of the attack of angina, the patient must stop physical exertion. The drug of choice is nitroglycerin (NTG and its inhalation forms) or isosorbide short-acting dinitrate, taken sublingual. The prevention of angina is achieved with the help of various forms of nitrates, including tablets of isosorbide di- or mononitrate for intake or (less often) transdermal plaster with nitroglycerin, placed once a day. Long-term therapy with nitrates limits the development of tolerance to them (i.e., reducing the effectiveness of the drug with a long, frequent use) appearing in part of patients, and cancellation syndrome - with a sharp discontinuation of drugs (symptoms of IBS exacerbation).
The undesirable effect of the development of tolerance can be prevented by creating a neglected gap to a duration of several hours, usually when the patient is sleeping. This is achieved by the intermittent appointment of short-acting nitrates or special forms of retardious mononitates.

Inhibitors of IF channels.
IF inhibitors of the cells of the sinus node cells - Ivabradin, selectively rejuvenating sinus rhythm, has a pronounced antiagonal effect, comparable to the effect of B-blockers. It is recommended for patients with contraindications to B-blockers or if it is impossible to receive B-blockers due to side effects.

Recommendations for pharmacotherapy, improving the forecast in patients with stable angina
Class I:
1. Acetylsalicylic acid 75 mg / day. In all patients in the absence of contraindications (active gastrointestinal bleeding, allergic to aspirin or its intolerance) (a).
2. Statins in all patients with ischemic heart disease (a).
3. IAPF in the presence of arterial hypertension, heart failure, left ventricle dysfunction, suffered myocardial infarction with left ventricle dysfunction or diabetes mellitus (A).
4. β-ab inside patients after myocardial infarction in history or heart failure (a).
Class IIA:
1. IAPF in all patients with angina and a confirmed diagnosis of coronary heart disease (B).
2. Clopidogrel as an alternative to aspirin in patients with stable angina, which cannot take aspirin, for example, due to allergies (B).
3. Statins in high doses in the presence of high risk (cardiovascular mortality\u003e 2% per year) in patients with proven ischemic heart disease (B).
Class IIB:
1. Fibrats with a low level of high density lipoproteins or high triglycerides in patients with diabetes mellitus or metabolic syndrome (B).

Recommendations for antianginal and / or anti-chemical therapy in patients with stable angina.
Class I:
1. Short-effect nitroglycerin to relieve angina and situational prevention (patients should obtain adequate instructions for the use of nitroglycerin) (B).
2. Evaluate the effectiveness of β, -ab and titrate its dose to the maximum therapeutic; Assess the feasibility of applying a long-acting drug (a).
3. With poor tolerability or low efficiency of β-AB, assign AK (A) monotherapy, a long-acting nitrate (C).
4. If the β-kc monotherapy is not effective enough, add dihydropyridine ak (B).
Class IIA:
1. With poor portability of β-ab, it is necessary to assign an inhibitor of channel I sinus node channels - Ivabradin (B).
2. If AK monotherapy or combined AK and β-AB therapy turns out to be ineffective, replace the AK to prolonged nitrate. Avoid the development of tolerance to nitrates (C).
Class IIB:
1. Preparations of metabolic type of action (TRIMETASIDIN MB) can be assigned to strengthen the antianginal efficiency of standard tools or as an alternative to them in intolerance or contraindications to use (B).

Basic drugs
Nitrate
- Nitroglycerin Table. 0.5 mg
- Isosorbide Mononitrate Cap. 40 mg
- Isosorbide Mononitrate Cap. 10-40 mg.
Beta blockers
- metoprolol Succinate 25 mg
- Bisoprolol 5 mg, 10 mg
AIF inhibitors
- Ramipril Tab. 5 mg, 10 mg
- Zofensoid 7.5 mg (preferably Purpose for HBP - SCF less than 30 ml / min)
Antiagreganta
- acetylsalicylic acid tab. Coated 75, 100 mg
Lampidemic means
- Rosavastatin Tab. 10 mg

Additional medicines
Nitrate
- Isosorbide Dinitrate Tab. 20 mg
- Isosorbide dynitrate dose aerosor
Beta blockers
- Carvedilol 6.25 mg, 25 mg
Calcium antagonists
- Amlodipine Tab. 2.5 mg
- Diltiazem Cap. 90 mg, 180 mg
- Verapamil Tab. 40 mg
- Nifedipin Tab. 20 mg
AIF inhibitors
- Perindopril Tab. 5 mg, 10 mg
- Captive Table. 25 mg
Angiotensin-II receptor antagonists
- Valsartan Tab. 80 mg, 160 mg
- Kandesartan Tab. 8 mg, 16 mg
Antiagreganta
- Clopidogrel Tab. 75 mg
Lampidemic means
- Atorvastatin Tab. 40 mg
- fenofibrate tab. 145 mg
- Tofizopas tab. 50mg.
- Diazepam Tab. 5mg.
- Diazepam AMP 2ml
- Spironolactone Tab. 25 mg, 50 mg
- Ivabradin Table. 5 mg
- Trimetazidine Table. 35 mg
- Ezomeprazole Liophilisate AMP. 40 mg
- Ezomeprazolet Tab. 40 mg
- Pantoprazole Tab. 40 mg
- sodium chloride 0.9% rr 200 ml, 400 ml
- Dextrose 5% Rr 200 ml, 400 ml
- Dobutamine * (load samples) 250 mg / 50 ml
Note: * Drugs not registered in the Republic of Kazakhstan, imported to permit for one-time import (order of the Ministry of Health of the Republic of Kazakhstan dated December 27, 12 No. 903 "On approval of maximum prices for drugs purchased within the guaranteed amount of free medical care for 2013").

Surgical intervention
Invasive treatment of stable angina is shown primarily to patients with high risk of complications, because Revascularization and drug treatment do not differ in the frequency of myocardial infarction and mortality. The effectiveness of chkb (stenting) and drug therapy was compared in several meta-analyzes and large RCCs. In most meta-analyzes, there was no decrease in mortality, an increase in the risk of non-infamous peripoclastory and reducing the need for re-revascularization after chkb was observed.
Balloon angioplasty in combination with the installation of the stent to prevent restenosis. Cytic stations covered with cytostatics (paclitaxel, sirolimus, everolimus and others) reduce the frequency of restenosis and repeated revascularization.
It is recommended to use stents that correspond to the following specifications:
Coronary stent with medicinal coating
1. Bathonorable seating stent Everoivamus on a fast shift system with a length of 143 cm. Materaya cobalt-chrome alloyl-605, wall thickness 0.0032 ". Material of a cylinder - pebax. Passage profile 0.041". Proximal shaft 0.031 ", distal - 034". Nonal pressure of 8 atm for 2.25-2.75 mm, 10 atm for 3.0-4.0 mm. Gap pressure - 18 atm. Length 8, 12, 15, 18, 23, 28, 33, 38 mm. Diameters 2.25, 2.5, 2.75, 3.0, 3.5, 4.0 mm. Dimensions on request.
2. Stanta material cobalt-chrome alloy L-605. Ballon material - FulCrum. Covered with a mixture of the drug Tyrolimus and Biolinx polymer. Cell thickness 0.091mm (0.0036 "). Delivery system 140 cm long 3.5 mm, 15 atm. For diameter 4.0 mm. Dimensions: diameter 2.25, 2.50, 2.75, 3.00, 3.50, 4.00 and the length of the stent (mm) -8, 9, 12, 14, 15, 18, 22, 22, 26, 30, 34, 38.
3. Stent material - platinum-chrome alloy. The proportion of platinum in the alloy is at least 33%. The proportion of nickel in the alloy is not more than 9%. The wall thickness of the stent is 0.0032. The stent drug coating consists of two polymers and a drug. The thickness of the polymer coating is 0.007 mm. The stent's profile on the delivery system is not more than 0.042 "(for a stent with a diameter of 3 mm). The maximum diameter of the paved seats of the stent is at least 5.77 mm (for a stent with a diameter of 3.00 mm). Stent diameters - 2.25 mm; 2.50 mm; 2.75 mm; 3.00 mm; 3.50 mm, 4.00 mm. Available stent lengths - 8 mm, 12 mm, 16 mm, 20 mm, 24 mm, 28 mm, 32 mm, 38 mm. Nominal pressure is at least 12 atm. Limit pressure - at least 18 atm. The profile of the tip of the toning system of the stent delivery system is not more than 0.017. The working length of the balloon catheter, on which the stent is mounted - at least 144 cm. The length of the tip of the delivering system is 1.75 mm. 5-petal cylinder laying technology. X-ray processed markers from platinum -Iridium alloy. X-ray radius markers - 0.94 mm.
4. Stent material: cobalt-chrome alloy, L-605. Passive covering: amorphous silicone carbide, active coating: biodegradable polylactide (L-PLA, Poly-L-Lactic Acid, PLLA) including Sirolimus. Stanta frame thickness with a nominal diameter of 2.0-3.0 mm no more than 60 microns (0.0024 "). Crossing Stant's profile - 0.039 "(0.994 mm). Stanta length: 9, 13, 15, 18, 22, 26, 30 mm. Nominal diameter of stents: 2.25 / 2.5 / 2.75 / 3.0 / 3.5 / 4.0 mm. Diameter of the distal end part (Input profile) - 0.017 "(0.4318 mm). The working length of the catheter is 140 cm. Nominal pressure of 8 atm. The calculated pressure of the breakdown of 16 atm. The diameter of the stent 2.25 mm at a pressure of 8 atmospheres: 2.0 mm. The diameter of the stent 2.25 mm at a pressure of 14 atmospheres: 2.43 mm.

Coronary stent without medicinal coating
1. The balllorscribable stent on the fast delivery system is 143 cm. Stanta material: non-magnetic cobalt-chrome alloy L-605. Ballon material - Pebax. Wall thickness: 0.0032 "(0.0813 mm). Diameters: 2.0, 2.25, 2.5, 2.75, 3.0, 3.5, 4.0 mm. Length: 8, 12, 15, 18, 23, 28 mm. Stent profile on the balloon 0.040" (stent 3.0x18 mm). The length of the working surface of the cylinder during the edges of the stent (Balloon Overhang) is not more than 0.69 mm. Complins: Nominal pressure (NP) 9 atm., Calculated rupture pressure (RBP) 16 atm.
2. Stanta material cobalt-chrome alloy L-605. Cell thickness 0.091 mm (0.0036 "). The delivery system is 140 cm long. The size of the proximal saffa of the catheter 0.69 mm, the distal satellite 0.91 mm. Rated pressure: 9 atm. Gap pressure 16 atm. For diameters 3.5 mm, 15 atm. For a diameter of 4.0 mm. Dimensions: diameter 2.25, 2.50, 2.75, 3.00, 3.50, 4.00 and the length of the stent (mm) - 8, 9, 12, 14, 15, 18, 22, 26, 30, 34, 38.
3. Stanta material - 316L stainless steel on a fast delivery system 145 cm long. The presence of a distal satellum coating (except for the stent). Delivery system design is a three-point balloon boat. Steten wall thickness, not more than 0.08 mm. Stanta design - open cell. The presence of low profile 0.038 "for a stent with a diameter of 3.0 mm. The ability to use conductive catheter with an internal diameter of 0.056" / 1.42 mm. 9 ATM cylinder nominal pressure for diameter 4 mm and 10 ATM for diameters from 2.0 to 3.5 mm; Pressure gap 14 ATM. The diameter of the proximal shaft - 2.0 FR, distal - 2.7 FR, diameters: 2.0; 2.25; 2.5; 3.0; 3.5; 4.0 Length 8; 10; 13; fifteen; eighteen; twenty; 23; 25; 30 mm.
Compared with drug therapy, the dilatation of the coronary arteries does not lead to a decrease in mortality and the risk of myocardial infarction in patients with stable angina, but increases the portability of the loads, reduces the frequency of angina and hospitalization. Before conducting the chkb, the patient receives a loading dose of clopidogrel (600 mg).
After implantation of stents without drugs, a combined therapy aspirin 75 mg / day is recommended for 12 weeks. and clopidogrel 75 mg / day, and further continue the reception of one aspirin. If the medicinal coating is implanted, combination therapy lasts until 12-24 months. If the risk of vascular thrombosis is high, the therapy with two disaggregants can be continued for more than a year.
Combined therapy with disaggregants in the presence of other risk factors (age\u003e 60 years, the reception of corticosteroids / NSAIDs, dyspepsia or heartburn) requires the prophylactic purpose of proton pump inhibitors (for example Rabeprazole, pantoprazole, etc.).

Contraindications for myocardial revascularization.
- Border stenosis (50-70%), except for the draft barrel, and the lack of signs of myocardial ischemia with a non-invasive study.
- insignificant stenosis< 50%).
- patients with sampling 1 or 2 ka without a pronounced proximal narrowing of the anterior downward artery, which have light symptoms of angina or there are no symptoms, and adequate drug therapy has been carried out.
- a high operational risk of complications or death (possible mortality\u003e 10-15%) except in cases where it is leveled by the expected significant improvement in survival or kzh.

Coronary shunting
Highlight two testimony to KSh: improving the forecast and reduce symptoms. Reducing mortality and risk of development to them is convincingly not proven.
Cardiac surgery consultation is necessary to determine the indications for surgical revascularization within the framework of a collegial solution (cardiologist + cardiac surgery + anesthesiologist + interventional cardiologist).

Table 7 - Indications for revascularization in patients with stable angina or hidden ischemia

OMT \u003d optimal medication therapy;

FRK \u003d Fractional Bleeding Reserve;
PNA \u003d front downward artery;
Lka \u003d Left coronary artery;
Chkb \u003d percutaneous coronary intervention.

Recommendations to revascularize myocardium in order to improve the forecast in patients with stable angina
Class I:
1. Coronary shunting with pronounced stenosis of the main trunk of the left coronary artery or a significant narrowing of the proximal segment of the left downward and envelope of the coronary arteries (a).
2. Coronary shunting with pronounced proximal stenosis 3 of the main coronary arteries, especially in patients with a reduced function of the left ventricle or quickly emerging or common reversible myocardial ischemia with functional samples (A).
3. Coronary shunting in the stenosis of one or 2 coronary arteries in combination with a pronounced narrowing of the proximal part of the left front descending artery and reversible myocardial ischemia during non-invasive studies (a).
4. Coronary shunting with pronounced stenosis of coronary arteries in combination with impaired function of the left ventricle and the presence of viable myocardium filed with non-invasive tests (B).
Class II A:
1. Coronary shunting during stenosis of one or 2 coronary arteries without a pronounced narrowing of the left front descending artery in patients who have undergone a sudden death or resistant ventricular tachycardia (B).
2. Coronary shunting with pronounced stenosis of 3 coronary arteries in patients with diabetes mellitus, which determine the signs of reversible myocardial ischemia during functional samples (C).

Preventive actions
Key lifestyle changes include smoking refusal and hard blood pressure control, tips on diet and weight control, as well as encouraging physical activity. Although the long-term management of this group of patients will respond to general practitioners, these measures will have more chances for implementation, if they are started during the patient's stay in the hospital. In addition, the advantages and importance of changing lifestyle should be explained and proposed to the patient - which is a key player - before discharge. However, the life habits are not easy to change, and the implementation and subsequent observation of these changes are a long-term task. In this regard, close cooperation between cardiologist and general practitioners, medical sisters, rehabilitation specialists, pharmacists, nutritionists, physiotherapists is critical.

To give up smoking
Patients who quit smoking reduced their mortality compared to those who continued to smoke. The refusal to smoking is the most effective of all secondary preventive measures and, therefore, it is necessary to make every effort to achieve this. However, frequent is the resumption of smoking by patients after discharge, and constant support and consultation are needed during the rehabilitation period. It can be useful to use substitutes for nicotine, buproprion and antidepressants. The non-smoking protocol must be accepted by each hospital.

Diet and weight control
Currently, the Prevention Guide recommends:
1. Rational Balanced Power;
2. control of calorie products to avoid obesity;
3. Increase the consumption of fruits and vegetables, as well as whole grain croup, fish (especially greasy varieties), lean meat and low-fat dairy products;
4. Replace saturated fats, mononaturated and polyunsaturated fats from vegetable and sea sources, as well as reduce the total amount of fats (of which less than one third should be saturated) to less than 30% of the total calorie consumption;
5. Restriction of salt consumption in accompanying arterial hypertension and heart failure.

Obesity is an ever-increasing problem. The current ECO leadership determines the body mass index (BMI) of less than 25 kg / m 2 as an optimal level, and recommends a weight loss with CMT 30 kg / m 2 or more, as well as during a waist circle more than 102 cm in men or more than 88 cm In women, since weight loss can improve many associated with obesity risk factors. However, it was not found that weight loss in itself reduces the mortality rate. Body mass index \u003d weight (kg): growth (m 2).

{!LANG-251695542ee23b8a5bd9d6628383b2c8!}
{!LANG-33197c0c130afb6a73fd6bafab97a258!}

{!LANG-856acc31e48d002a735f22d883eaaedd!}
{!LANG-212096697deb871f0f94e0bb5c66ff6a!}

{!LANG-f60c33995dbd6a2185b8227f4ca0037b!}
{!LANG-e95b7860cc3b5e5d81d49946ca4332d1!}
{!LANG-3f8a8a4d5457bfc9b8f818dbd32d7480!}
{!LANG-c7244368b9c1de3d2b145589e1f98a85!}
{!LANG-2cf90fdcd275f4cc6ae28f7e8886bc2a!}
{!LANG-209ccff22df452d825f7151d4dd0cef7!}
{!LANG-4892d8acea1410cba353ffbc6157eac5!}
{!LANG-ab7e3fc8940c05c3cff29cea823552aa!}
{!LANG-0272f77d0545b42259d57fdcda6c4b82!}

{!LANG-f8980ed9f1c1fad5d0183e9976a82ce0!}{!LANG-c0e866df296e34c3312187995179a952!}
{!LANG-e4c0b9c1f9af2b044bf9dad96a00782e!}
{!LANG-a69c38a2c2da79550c3dc47e99c589bf!}
{!LANG-d59d9dd9f5a0de8c9ef81855b30a08b2!}
{!LANG-d76d240bfe47af6b82041bbb17757557!}
{!LANG-284b5ba5e200596007cdc2d094ea04cb!}

{!LANG-c54992be49eb0f3f12e8a2fa8fdf4936!}
{!LANG-3964b146fe1c0729994c7c99a5ee5729!}

{!LANG-fa617a93915b6b790e94c90e052d4e5c!}
{!LANG-fa17050136e00fa1353e904280aa339d!}
{!LANG-3a1d7f1b1a4ac9cf4f7a320b4cbe23d5!}

{!LANG-3282c3d2d938790a9cd941e2c4117d48!}
{!LANG-ba8e16dd61545f83fd0abc4afa272623!}

{!LANG-8e96937c2c47e91d6e241c5b5f962698!}
{!LANG-51fabb5ae0af57d90e9032dabc3eacf9!}

{!LANG-61f7d60d1c2ac5266a5bd838e101c2e5!}
{!LANG-6c70c5cd525816d8de42230ef1924d5d!}

{!LANG-cde18dcfee0c3f2ce01c9b1c99105feb!}

{!LANG-9351d47e364f08c35c21f3ffec515d14!}
{!LANG-afdb534706ade3e804036a4871b0bb6a!}

Information

{!LANG-44b37040ebb6c47a224ae3814e5aab88!}

1. {!LANG-3debc393a4fe42f771b648751651e7e8!}
   1. {!LANG-15982793be33df25bf5b8eeedc290efd!}

Information

{!LANG-3d69145f2ae1043b74f9e2d492858ec6!}

{!LANG-727406b20e3badb2b7f0c56462b1edfc!}
{!LANG-327cb036c7fbd6c185ab18a87ba75d21!}
{!LANG-68edcd1d9e35eff35d33d812c059d6dc!}
{!LANG-42f9bd50ddcbdbc9ceeb78c92adf694b!}
{!LANG-3bb9513fe15f65e61844b1a1f3bc90b9!}
{!LANG-4ade0eaa89b4ab7262df9125f0029469!}

{!LANG-153642c93cfcccd7b15b0061d708a142!}
{!LANG-3df38dd2b5cbfb8bee82f5cf4d75a6d7!}

{!LANG-f2b38195e86967cf3f70ed5b096a6a13!}{!LANG-59ca11ae8c81a6900b8913780795c1b0!}

{!LANG-5c7329eabcdd46a3f379ce0fb2553d92!}{!LANG-b1c723867321799fcde08f3aa82ea6f0!}

{!LANG-cb79ae79d7526732b98b40cc4943e0ff!}

{!LANG-7775dcd99ca95021bdbe3ff1dce0327b!}

• {!LANG-b7cc54cb019c2525317420737383f9b5!}
• {!LANG-b1c77e6480c6e900b3774fabb60a5bce!}
• {!LANG-1a17ed1b702cc78c6f8e7bfe68eab39f!}
• {!LANG-f7acc6d622b5d5d111e4b42c600b1612!}
• {!LANG-117ef970e11401512e6e07b9f4434012!}