general information

Short description
Approved by the Protocol
of the Expert Commission on Healthcare Development
of June 28, 2013

IHD is an acute or chronic heart disease caused by a decrease or cessation of blood

supply to the myocardium due to a disease process in the coronary vessels (WHO
definition 1959).

Angina is a clinical syndrome manifested by a feeling of discomfort or pain in the

chest of a compressive, pressing nature, which is most often localized behind the
sternum and can radiate to the left arm, neck, lower jaw, and epigastric region. Pain is
provoked by physical activity, going out into the cold, eating a lot of food, and
emotional stress; goes away with rest or is eliminated by taking sublingual
nitroglycerin within a few seconds or minutes.

I. INTRODUCTORY PART

Name: IHD stable angina pectoris

Protocol code:

ICD-10 codes:
I20.8 - Other forms of angina

Abbreviations used in the protocol:

AG - arterial hypertension
AA - antianginal (therapy)
BP - blood pressure
CABG - aorto- coronary artery bypass surgery
ALT - alanine aminotransferase
AO - abdominal obesity
ACT - aspartate aminotransferase
CCB - calcium channel blockers
GPs - general practitioners VPN
- upper limit norm UPU
- Wolff-Parkinson-White syndrome HCM
- hypertrophic cardiomyopathy
LVH - left ventricular hypertrophy
DBP - diastolic blood pressure
DLP - dyslipidemia
PVC - ventricular extrasystole
IHD - coronary heart disease BMI
- body mass index
ICD - short-acting insulin CAG -
coronary angiography
CA - coronary arteries
CPK - creatine phosphokinase
MS - metabolic syndrome
IGT - impaired glucose tolerance
NVII - continuous intravenous insulin therapy
TC - total cholesterol
ACS BPST - acute coronary syndrome without ST segment elevation
ACS SPST - acute coronary syndrome with ST segment elevation
OT - waist circumference
SBP - systolic blood pressure
DM - diabetes mellitus
GFR - glomerular filtration rate
ABPM - 24-hour blood pressure monitoring
TG - triglycerides
IMT - thickness of the intima-media complex
TSH - glucose tolerance test
U3DG - ultrasound Dopplerography
FA - physical activity
FC - functional class
FN - physical activity
FR - risk factors
COPD - chronic obstructive pulmonary disease
CHF - chronic heart failure
HDL cholesterol - high lipoprotein cholesterol
LDL cholesterol density - low-density lipoprotein cholesterol
4KB - percutaneous coronary intervention
HR - heart rate ECG
- electrocardiography
ECS - pacemaker
EchoCG - echocardiography
VE - minute volume of respiration
VCO2 - the amount of carbon dioxide released per unit time;
RER (respiratory quotient) - VCO2/VO2 ratio;
BR - respiratory reserve.
BMS - non-drug eluting stent
DES - drug eluting stent

Date of protocol development: 2013.

Category of patients: adult patients undergoing inpatient treatment with a diagnosis
of coronary artery disease and stable angina pectoris.
Users of the protocol: general practitioners, cardiologists, interventional
cardiologists, cardiac surgeons.

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Classification

Clinical classification

Table 1. Classification of the severity of stable angina pectoris according to the

Canadian Heart Association classification (Campeau L, 1976)

FC Signs

Normal daily physical activity (walking or climbing stairs) does not cause angina.
I Pain occurs only when performing very intense, and very fast, or prolonged
physical activity.

Slight limitation of usual physical activity, which means the occurrence of angina
when walking quickly or climbing stairs, in cold or windy weather, after eating,
II during emotional stress, or in the first few hours after waking up; while walking >
200 m (two blocks) on level ground or while climbing more than one flight of
stairs in normal

Significant limitation of usual physical activity - angina occurs as a result of calm

III walking for a distance of one to two blocks (100-200 m) on level ground or when
climbing one flight of stairs in normal

The inability to perform any physical activity without the appearance of

IV unpleasant sensations, or angina pectoris can occur at rest, with minor physical
exertion, walking on level ground for a distance of less than

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Laboratory tests:
1. BC
2. TAM
3. Blood sugar
4. Blood creatinine 5.
Total protein
6. ALT
7. Blood electrolytes
8. Blood lipid spectrum
9. Coagulogram
10. ELISA for HIV (before CAG)
11. ELISA for markers of viral hepatitis (before CAG)
12. Score for i/g
13. Blood for microreaction.

Instrumental examinations:
1. ECG
2. EchoCG
3. FG/x-ray of the OGK
4. EGDS (as indicated)
5. ECG with stress (VEM, treadmill test)
6. Stress EchoCG (as indicated)
7. Daily Holter ECG monitoring (according to indications)
8. Coronary angiography

Diagnostic criteria

Complaints and anamnesis

The main symptom of stable angina is a feeling of discomfort or pain in the chest of a
compressive, pressing nature, which is most often localized behind the sternum and
can radiate to the left arm, neck, lower jaw, epigastric region.
The main factors that provoke chest pain: physical activity - brisk walking, climbing a
mountain or stairs, carrying heavy objects; increased blood pressure; cold; large
meals; emotional stress. Usually the pain goes away with rest after 3-5 minutes. or
within seconds or minutes after taking sublingual nitroglycerin tablets or spray.
Table 2 - Symptom complex of angina pectoris

Signs Characteristic

Localization of the most typical is behind the sternum, often in the upper
pain/discomfort part, the “clenched fist” symptom.

in the neck, shoulders, arms, lower jaw, most often on the

Irradiation left, epigastrium and back, sometimes there may be only
radiating pain, without substernal pain.

unpleasant sensations, a feeling of compression, tightness,

Character
burning, suffocation, heaviness.

Duration (duration) more often 3-5 minutes

has a beginning and an end, increases gradually, stops

Seizures
quickly, leaving no unpleasant sensations.

Intensity (severity) from moderate to unbearable.

Conditions for physical activity, emotional stress, in the cold, with heavy
attack/pain food or smoking.

Conditions
(circumstances)
stopping or reducing the load by taking nitroglycerin.
causing the cessation
of pain

Uniformity
Each patient has his own pain stereotype
(stereotypicity)

the patient's position is frozen or excited, shortness of

Associated symptoms
breath, weakness, fatigue, dizziness, nausea, sweating,
and patient behavior
anxiety, etc. confusion.

Duration and nature of

the disease, dynamics determine the course of the disease in each patient.
of symptoms

Table 3 - Clinical classification of chest pain

Typical Meets three of the presented criteria: - retrosternal discomfort with
angina typical characteristics - provoked by physical tension or emotional
(definitely) stress - relieved after rest or taking nitroglycerin

Atypical
angina Meets two of the presented criteria
(probably)

Non-
cardiac Meets one or none of the criteria presented
pain

When collecting anamnesis, it is necessary to note the risk factors for coronary artery
disease: male gender, old age, dyslipidemia, hypertension, smoking, diabetes mellitus,
increased heart rate, low physical activity, excess body weight, alcohol abuse.

Conditions that provoke myocardial ischemia or aggravate its course are analyzed:
increasing oxygen consumption:
- non-cardiac: hypertension, hyperthermia, hyperthyroidism, intoxication with
sympathomimetics (cocaine, etc.), agitation, arteriovenous fistula;
- cardiac: HCM, aortic heart defects, tachycardia.
reducing oxygen supply:
- non-cardiac: hypoxia, anemia, hypoxemia, pneumonia, bronchial asthma, COPD,
pulmonary hypertension, sleep 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 assess the body mass index (BMI) and waist circumference,
determine heart rate, pulse parameters, blood pressure in both arms;
- you can detect signs of lipid metabolism disorders: xanthomas, xanthelasmas,
marginal opacification of the cornea of the eye (“senile arch”) and stenosing lesions of
the main arteries (carotid, subclavian peripheral arteries of the lower extremities, etc.);
- during physical activity, sometimes at rest, during auscultation the 3rd or 4th heart
sounds can be heard, as well as systolic murmur at the apex of the heart, as a sign of
ischemic dysfunction of the papillary muscles and mitral regurgitation;
- pathological pulsation in the precordial region indicates the presence of a cardiac
aneurysm or expansion of the borders of the heart due to pronounced hypertrophy or
dilatation of the myocardium.

Instrumental studies

Electrocardiography in 12 leads is a mandatory method for diagnosing myocardial

ischemia in stable angina. Even in patients with severe angina, changes in the ECG at
rest are often absent, which does not exclude the diagnosis of myocardial ischemia.
However, the ECG may reveal signs of coronary heart disease, for example, a previous
myocardial infarction or repolarization disorders. An ECG may be more informative if it
is recorded during an attack of pain. In this case, it is possible to detect ST segment
displacement due to myocardial ischemia or signs of pericardial damage. Registration
of an ECG during stool and pain is especially indicated if the presence of vasospasm
is suspected. Other changes that may be detected on the ECG include left ventricular
hypertrophy (LVH), bundle branch block, ventricular preexcitation syndrome,
arrhythmias, or conduction disturbances.

Echocardiography : 2D and resting Doppler echocardiography can rule out other

heart diseases, such as valvular disease or hypertrophic cardiomyopathy, and
examine ventricular function.

Recommendations for echocardiography in patients with stable angina

Class I:
1. Auscultatory changes indicating the presence of valvular heart disease or
hypertrophic cardiomyopathy (B)
2. Signs of heart failure (B)
3. Previous myocardial infarction (B)
4. Left bundle branch block His, Q waves or other significant pathological changes on
the ECG (C)

Daily ECG monitoring is indicated:

- for the diagnosis of silent myocardial ischemia;
- to determine the severity and duration of ischemic changes;
- to detect vasospastic angina or Prinzmetal angina.
- for diagnosing rhythm disturbances;
- to assess heart rate variability.

The criterion for myocardial ischemia during 24-hour ECG monitoring (CM) is ST
segment depression > 2 mm with a duration of at least 1 min. The duration of ischemic
changes according to SM ECG data is important. If the total duration of ST segment
depression reaches 60 minutes, then this can be regarded as a manifestation of
severe CAD and is one of the indications for myocardial revascularization.

Recommendations for ambulatory ECG monitoring in patients with angina

Class I: Angina accompanied by rhythm disturbances (B)
Class IIa: Suspicion of vasospastic angina

Exercise ECG:Exercise testing is a more sensitive and specific method for diagnosing
myocardial ischemia than resting ECG.
Recommendations for performing an exercise test in patients with stable angina
Class I:
1. The test should be performed in the presence of symptoms of angina and a
moderate/high probability of coronary heart disease (taking into account age, sex and
clinical manifestations) unless the test cannot be performed because of exercise
intolerance or changes in the resting ECG (B).
Class IIb:
1. Presence of resting ST segment depression ≥1 mm or treatment with digoxin (B).
2. Low probability of having coronary heart disease (less than 10%), taking into
account age, gender and the nature of clinical manifestations (B).

Reasons for stopping exercise testing:

1. Onset of symptoms such as chest pain, fatigue, shortness of breath or claudication.
2. The combination of symptoms (for example, pain) with pronounced changes in the
ST segment.
3. Patient safety:
a) severe ST segment depression (>2 mm; if ST segment depression is 4 mm or more,
then this is an absolute indication to stop the test);
b) ST segment elevation ≥2 mm;
c) the appearance of a threatening rhythm disturbance;
d) persistent decrease in systolic blood pressure by more than 10 mm Hg. Art.;
e) high arterial hypertension (systolic blood pressure more than 250 mm Hg or
diastolic blood pressure more than 115 mm Hg).
4. Achieving the maximum heart rate can also serve as a basis for stopping the test in
patients with excellent exercise tolerance who do not show signs of fatigue (the
decision is made by the doctor at his own discretion).
5. Refusal of the patient from further examination.

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

FC
Indicators
I II III IV

Number of metabolic units (treadmill) >7.0 4.0-6.9 2.0-3.9 <2.0

“Double product” (HR • SBP • 10-2) >278 218-277 15l-217 <150

Power of the last load stage, W (VEM) >125 75-100 50 25

Stress echocardiography is superior to stress ECG in prognostic value, has greater

sensitivity (80-85%) and specificity (84-86%) in the diagnosis of coronary artery
disease.

Myocardial perfusion scintigraphy with stress. The method is based on the

Sapirstein fractional principle, according to which the radionuclide during the first
circulation is distributed in the myocardium in quantities proportional to the coronary
fraction of cardiac output and reflects the regional distribution of perfusion. The FN
test is a more physiological and preferable method for reproducing myocardial
ischemia, but pharmacological tests can be used.

Recommendations for performing stress echocardiography and myocardial

scintigraphy in patients with stable angina
Class I:
1. Presence of changes on the ECG at rest, left bundle branch block, ST segment
depression of more than 1 mm, pacemaker or Wolff-Parkinson-White syndrome that
does not allow interpret the results of the stress ECG (B).
2. Ambiguous results of an exercise ECG with acceptable tolerance in a patient with a
low probability of coronary heart disease, if the diagnosis is in doubt (B)
Class IIa:
1. Determination of the localization of myocardial ischemia before myocardial
revascularization (percutaneous intervention on the coronary arteries or coronary
artery bypass grafting) ( IN).
2. An alternative to exercise ECG if appropriate equipment, personnel and facilities are
available (B).
3. An alternative to stress ECG when the likelihood of coronary heart disease is low,
for example, in women with atypical chest pain (B).
4. Assessment of the functional significance of moderate coronary artery stenosis
identified by angiography (C).
5. Determination of the localization of myocardial ischemia when choosing a
revascularization method in patients who underwent angiography (B).

Recommendations for the use of echocardiography or myocardial scintigraphy with a

pharmacological test in patients with stable angina pectoris
Class I, IIa and IIb:
1. The indications listed above, if the patient cannot perform adequate exercise.

Multislice computed tomography of the heart and coronary vessels:

- is prescribed for the examination of men aged 45-65 years and women aged 55-75
years without established CVD for the purpose of early detection of initial signs of
coronary atherosclerosis;
- as an initial diagnostic test in an outpatient setting in patients aged < 65 years with
atypical chest pain in the absence of an established diagnosis of coronary artery
disease;
- as an additional diagnostic test in patients aged < 65 years with questionable results
of stress tests or the presence of traditional coronary risk factors in the absence of an
established diagnosis of coronary artery disease;
- to carry out a differential diagnosis between CHF of ischemic and non-ischemic
origin (cardiopathy, myocarditis).

Cardiac Magnetic Resonance Imaging

Stress MRI can be used to identify dobutamine-induced LV wall asynergies or
adenosine-induced perfusion abnormalities. The technique is new and therefore less
studied than other non-invasive imaging techniques. The sensitivity and specificity of
LV contractility abnormalities detected by MRI are 83% and 86%, respectively, and
perfusion abnormalities are 91% and 81%. Stress perfusion MRI has similar high
sensitivity but reduced specificity.
Magnetic resonance coronary angiography
MRI is characterized by a lower success rate and less accuracy in diagnosing
coronary artery disease than MSCT.

Coronary angiography (CAT) is the main method for diagnosing the condition of the
coronary bed. CAG allows you to choose the optimal treatment method: medication or
myocardial revascularization.
Indications for prescribing CAG to a patient with stable angina when deciding on the
possibility of performing PCI or CABG:
- severe angina of class III-IV, persisting with optimal antianginal therapy;
- signs of severe myocardial ischemia according to the results of non-invasive
methods;
- the patient has a history of episodes of VS or dangerous ventricular arrhythmias;
- progression of the disease according to the dynamics of non-invasive tests;
- early development of severe angina (FC III) after MI and myocardial revascularization
(up to 1 month);
- questionable results of non-invasive tests in persons with socially significant
professions (public transport drivers, pilots, etc.).

There are currently no absolute contraindications for prescribing CAG.

Relative contraindications to CAG:
- Acute renal failure
- Chronic renal failure (blood creatinine level 160-180 mmol/l)
- Allergic reactions to contrast agent and iodine intolerance
- Active gastrointestinal bleeding, exacerbation of peptic ulcer
- Severe coagulopathies
- Severe anemia
- Acute cerebrovascular accident
- Severe disturbance of the patient’s mental state
- Serious concomitant diseases that significantly shorten the patient’s life or sharply
increase the risk
of subsequent therapeutic interventions - The patient’s refusal of possible further
treatment after the study (endovascular intervention, CABG) -
Severe damage to the peripheral arteries, limiting arterial access
- Decompensated HF or acute pulmonary edema
- Malignant hypertension , difficult to respond to drug treatment
- Intoxication with cardiac glycosides
- Severe disturbance of electrolyte metabolism
- Fever of unknown etiology and acute infectious diseases
- Infectious endocarditis
- Exacerbation of severe non-cardiological chronic disease

Recommendations for chest radiography in patients with stable angina

Class I:
1. Chest radiography is indicated for presence of symptoms of heart failure (C).
2. Chest X-ray is warranted if there are signs of pulmonary involvement (B).

Fibrogastroduodenoscopy (FGDS) (according to indications), examination for

Helicobtrcter Pylori (according to indications).

Indications for consultation with specialists

Endocrinologist - diagnosis and treatment of disorders of glycemic status, treatment
of obesity, etc., teaching the patient the principles of dietary nutrition, transferring to
treatment with short-acting insulin before planned surgical revascularization;
Neurologist - presence of symptoms of brain damage (acute cerebrovascular
accidents, transient cerebrovascular accidents, chronic forms of vascular pathology
of the brain, etc.);
Ophthalmologist - presence of symptoms of retinopathy (according to indications);
Angiosurgeon - diagnosis and treatment recommendations for atherosclerotic
lesions of peripheral arteries.

Laboratory diagnostics

Recommendations for laboratory testing of patients with stable angina

Class I (all patients)

1. Fasting lipid levels, including total cholesterol, LDL, HDL and triglycerides (B)
2. Fasting glycemia (B)
3. Complete blood count, including hemoglobin and leukocyte count (B)
4. Creatinine level (C), calculation of creatinine clearance
5. Indicators of thyroid function (according to indications) (C)
Class IIa
Oral glucose load test (B)

Class IIb
1. High-sensitivity C-reactive protein (B)
2 Lipoprotein (a), ApoA and ApoB (B)
3. Homocysteine (B)
4. HbAlc (B)
5. NT-BNP

Table 4 - Assessment of lipid spectrum indicators

Normal
Target level for ischemic heart disease and diabetes
Lipids level
(mmol/l)
(mmol/l)

General HS <5.0 <14.0

LDL
<3.0 <:1.8
cholesterol

HDL
≥1.0 in men, ≥1.2 in women
cholesterol

Triglycerides <1.7

List of basic and additional diagnostic measures

Basic studies
1. General blood test
2. Determination of glucose
3. Determination of creatinine
4. Determination of creatinine clearance
5. Determination of ALT
6. Determination of PTI
7. Determination of fibrinogen
8. Determination of MHO
9. Determination of total cholesterol
10. Determination LDL
11. HDL determination
12. Triglyceride determination
13. Potassium/sodium determination
14. Calcium
determination 15. Urinalysis
16. ECG
17.3XOK
18. ECG exercise test (VEM/treadmill)
19. Stress EchoCG

Additional studies
1 Glycemic profile
2. Chest X-ray
3. EGD
4. Glycated hemoglobin
5. Oral glucose load test
6. NT-proBNP
7. Determination of hs-CRP
8. Determination of ABC
9. Determination of APTT
10. Determination of magnesium
11. Determination total bilirubin
12. CM blood pressure
13. CM Holter ECG
14. Coronary angiography
15. Myocardial perfusion scintigraphy / SPECT
16. Multislice computed tomography
17. Magnetic resonance imaging
18. PET

Differential diagnosis

Differential diagnosis

Table 6 - Differential diagnosis of chest pain

Cardiovascular causes

Ischemic

Coronary artery stenosis restricting blood flow

Coronary vasospasm

Microvascular dysfunction

Non-ischemic

Stretching of the wall of the coronary artery

Uncoordinated contraction of myocardial fibers

Aortic dissection

Pericarditis

Pulmonary embolism or hypertension

Non-cardiac causes

Gastrointestinal

Esophageal spasm

Gastroesophageal reflux

Gastritis/duodenitis

Peptic ulcer

Cholecystitis

Respiratory

Pleurisy

Mediastinitis

Pneumothorax

Neuromuscular/skeletal

Chest pain syndrome

Neuritis/radiculitis

Shingles
Tietze syndrome

Psychogenic

Anxiety

Depression

Coronary syndrome X
The clinical picture suggests the presence of three signs:
- typical angina that occurs during exercise (less commonly, angina or shortness of
breath at rest);
- positive result of ECG with physical function or other stress tests (ST segment
depression on ECG, myocardial perfusion defects on scintigrams);
- normal coronary arteries on CAG.

Treatment

Treatment goals:
1. Improve the prognosis and prevent the occurrence of myocardial infarction and
sudden death and, accordingly, increase life expectancy.
2. Reduce the frequency and intensity of angina attacks and, thus, improve the
patient’s quality of life.

Treatment tactics

Non-drug treatment:
1. Informing and educating the patient.

2. Stop smoking.

3. Individual recommendations for acceptable physical activity depending on the FC

of angina and the state of LV function. It is recommended to do physical exercises
because... they lead to an increase in FTN, a decrease in symptoms and have a
beneficial effect on BW, lipid levels, blood pressure, glucose tolerance and insulin
sensitivity. Moderate exercise for 30-60 minutes ≥5 days a week, depending on the
FC of angina (walking, light jogging, swimming, cycling, skiing).
4. Recommended diet: eating a wide range of foods; control of food calories to avoid
obesity; increasing the consumption of fruits and vegetables, as well as whole grain
cereals and breads, fish (especially fatty varieties), lean meats and low-fat dairy
products; replace saturated fats and trans fats with monounsaturated and
polyunsaturated fats from vegetable and marine sources, and reduce total fat (of
which less than one-third should be saturated) to less than 30% of total calories
consumed, and reduce salt intake , with an increase in blood pressure. A body mass
index (BMI) of less than 25 kg/m2 is considered normal and weight loss is
recommended for a BMI of 30 kg/m2 or more, as well as for a waist circumference of
more than 102 cm in men or more than 88 cm in women, since weight loss may
improve many obesity-related risk factors.

5. Alcohol abuse is unacceptable.

6. Treatment of concomitant diseases: for hypertension - achieving a target blood

pressure level of <130 and 80 mmHg, for diabetes - achieving quantitative
compensation criteria, treatment of hypo- and hyperthyroidism, anemia.

7. Recommendations for sexual activity - sexual intercourse can provoke the

development of angina, so you can take nitroglycerin before it. Phosphodiesterase
inhibitors: sildenafil (Viagra), tadafil and vardenafil, used to treat sexual dysfunction,
should not be used in combination with long-acting nitrates.

Drug treatment
Drugs that improve the prognosis in patients with angina pectoris:
1. Antiplatelet drugs:
- acetylsalicylic acid (dose 75-100 mg/day - long-term).
- in patients with aspirin intolerance, the use of clopidogrel 75 mg per day is indicated
as an alternative to aspirin
- dual antiplatelet therapy with aspirin and oral use of ADP receptor antagonists
(clopidogrel, ticagrelor) should be used for up to 12 months after 4KB, with a strict
minimum for patients with BMS - 1 month, patients with DES - 6 months.
- Gastric protection using proton pump inhibitors should be performed during dual
antiplatelet therapy in patients at 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 prostheses),
they should be used in addition to antiplatelet therapy.

2. Lipid-lowering drugs that reduce LDL cholesterol levels:

- Statins. The most studied statins for ischemic heart disease are atorvastatin 10-40
mg and rosuvastatin 5-40 mg. The dose of any statin should be increased at an
interval of 2-3 weeks, since during this period the optimal effect of the drug is
achieved. The target level is determined by LDL cholesterol - less than 1.8 mmol/l.
Monitoring indicators during treatment with statins:
- it is necessary to initially take a blood test for lipid profile, AST, ALT, CPK.
- after 4-6 weeks of treatment, the tolerability and safety of treatment should be
assessed (patient complaints, repeated blood tests for lipids, AST, ALT, CPK).
- when titrating doses, they are primarily focused on the tolerability and safety of
treatment, and secondly, on achieving target lipid levels.
- if the activity of liver transaminases increases by more than 3 VPN, it is necessary to
repeat the blood test again. It is necessary to exclude other causes of
hyperfermentemia: drinking alcohol the day before, cholelithiasis, exacerbation of
chronic hepatitis or other primary and secondary liver diseases. The cause of
increased CPK activity may be damage to skeletal muscles: intense physical activity
the day before, intramuscular injections, polymyositis, muscular dystrophy, trauma,
surgery, myocardial damage (MI, myocarditis), hypothyroidism, CHF.
- if AST, ALT >3 VPN, CPK > 5 VPN, statins are canceled.
- An inhibitor of intestinal cholesterol absorption - ezetimibe 5-10 mg 1 time per day -
inhibits the absorption of dietary and biliary cholesterol in the villous epithelium of the
small intestine.

Indications for the use of ezetimibe:

- as monotherapy for the treatment of patients with the heterozygous form of FH who
cannot tolerate statins;
- in combination with statins in patients with a heterozygous form of FH, if the LDL-C
level remains high (more than 2.5 mmol/l) against the background of the highest
doses of statins (simvastatin 80 mg/day, atorvastatin 80 mg/day) or poor tolerance of
high doses of statins. The fixed combination is the drug Ineji, which contains
ezetimibe 10 mg and simvastatin 20 mg in one tablet.

3. β-blockers
The positive effects of this group of drugs are based on reducing the myocardial
oxygen demand. BL-selective blockers include: atenolol, metoprolol, bisoprolol,
nebivolol, non-selective - propranolol, nadolol, carvedilol.
β - blockers should be preferred in patients with coronary artery disease with: 1) the
presence of heart failure or left ventricular dysfunction; 2) concomitant arterial
hypertension; 3) supraventricular or ventricular arrhythmia; 4) previous myocardial
infarction; 5) the presence of a clear connection between physical activity and the
development of an attack of angina.
The effect of these drugs in stable angina can only be counted on if, when prescribed,
a clear blockade of β-adrenergic receptors is achieved. To do this, you need to
maintain your resting heart rate within 55-60 beats/min. In patients with more severe
angina, the heart rate can be reduced to 50 beats/min, provided that such bradycardia
does not cause discomfort and AV block does not develop.
Metoprolol succinate 12.5 mg twice a day, if necessary increasing the dose to 100-
200 mg per day with twice a day.
Bisoprolol - starting with a dose of 2.5 mg (with existing decompensation of CHF -
from 1.25 mg) and, if necessary, increasing to 10 mg for a single dose.
Carvedilol - starting dose 6.25 mg (for hypotension and symptoms of CHF 3.125 mg)
in the morning and evening with a gradual increase to 25 mg twice.
Nebivolol - starting with a dose of 2.5 mg (with existing decompensation of CHF -
from 1.25 mg) and, if necessary, increasing to 10 mg, once a day.

Absolute contraindications to the use of beta blockers for coronary artery disease
are severe bradycardia (heart rate less than 48-50 per minute), 2-3 degree
atrioventricular block, sick sinus syndrome.

Relative contraindications - bronchial asthma, COPD, acute heart failure, severe

depression, peripheral vascular disease.

4. ACE inhibitors or ARA II

ACE inhibitors are prescribed to patients with coronary artery disease if there are
signs of heart failure, arterial hypertension, diabetes mellitus and there are no
absolute contraindications to their use. Drugs with a proven effect on long-term
prognosis are used (ramipril 2.5-10 mg once daily, perindopril 5-10 mg once daily,
fosinopril 10-20 mg daily, zofenopril 5-10 mg, etc.). If ACEIs are intolerant, angiotensin
II receptor antagonists with a proven positive effect on long-term prognosis for
coronary artery disease (valsartan 80-160 mg) can be prescribed.

5. Calcium antagonists (calcium channel blockers).

They are not the main means in the treatment of coronary artery disease. May relieve
symptoms of angina pectoris. The effect on survival and complication rates in
contrast to beta blockers has not been proven. Prescribed when there are
contraindications to the use of b-blockers or their insufficient effectiveness in
combination with them (with dihydropyridines, except short-acting nifedipine).
Another indication is vasospastic angina.
Currently, long-acting CCBs (amlodipine) are mainly recommended for the treatment
of stable angina; they are used as second-line drugs if symptoms are not eliminated
by b-blockers and nitrates. CCBs should be preferred in case of concomitant: 1)
obstructive pulmonary diseases; 2) sinus bradycardia and severe atrioventricular
conduction disturbances; 3) variant angina (Prinzmetal).

6. Combination therapy (fixed combinations) for patients with stable angina

pectoris II-IV class is carried out for the following indications: impossibility of selecting
effective monotherapy; the need to enhance the effect of monotherapy (for example,
during periods of increased physical activity of the patient); correction of unfavorable
hemodynamic changes (for example, tachycardia caused by CCBs of the
dihydropyridine group or nitrates); when angina is combined with hypertension or
heart rhythm disturbances that are not compensated for in cases of monotherapy; in
case of intolerance to the patient of generally accepted doses of AA drugs during
monotherapy (in this case, to achieve the necessary AA effect, small doses of drugs
can be combined; in addition to the main AA drugs, other drugs are sometimes
prescribed (potassium channel activators, ACE inhibitors, antiplatelet agents). When
carrying out AA
therapy one should strive for almost complete elimination of anginal pain and the
return of the patient to normal activity. However, therapeutic tactics do not give the
necessary effect in all patients. In some patients, during exacerbation of coronary
heart disease, an aggravation of the severity of the condition is sometimes observed.
In these cases, consultation with cardiac surgeons is necessary in order to provide the
patient with cardiac surgery Relief

and prevention of anginal pain:

Anginal therapy solves symptomatic problemsin restoring the balance between the
need and delivery of oxygen to the myocardium.

Nitrates and nitrate-like. If an angina attack develops, the patient should stop
physical activity. The drug of choice is nitroglycerin (NTG and its inhaled forms) or
short-acting isosorbide dinitrate, taken sublingually. Prevention of angina is achieved
with various forms of nitrates, including oral isosorbide di- or mononitrate tablets or
(less commonly) a once-daily nitroglycerin transdermal patch. Long-term therapy with
nitrates is limited by the development of tolerance to them (i.e., a decrease in the
effectiveness of the drug with prolonged, frequent use), which appears in some
patients, and withdrawal syndrome - with an abrupt cessation of taking the drugs
(symptoms of exacerbation of coronary artery disease).
The undesirable effect of developing tolerance can be prevented by providing a
nitrate-free interval of several hours, usually while the patient is asleep. This is
achieved by intermittent administration of short-acting nitrates or special forms of
retard mononitrates.

If channel inhibitors.
Inhibitors of If channels of sinus node cells - Ivabradine, which selectively reduce
sinus rhythm, have a pronounced antianginal effect, comparable to the effect of b-
blockers. Recommended for patients with contraindications to b-blockers or if it is
impossible to take b-blockers due to side effects.

Recommendations for pharmacotherapy that improves the prognosis in patients

with stable angina pectoris
Class I:
1. Acetylsalicylic acid 75 mg/day. in all patients in the absence of contraindications
(active gastrointestinal bleeding, allergy to aspirin or intolerance to it) (A).
2. Statins in all patients with coronary heart disease (A).
3. ACEI in the presence of arterial hypertension, heart failure, left ventricular
dysfunction, previous myocardial infarction with left ventricular dysfunction or
diabetes mellitus (A).
4. β-AB orally to patients after a history of myocardial infarction or with heart failure
(A).
Class IIa:
1. ACEI 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 who cannot
take aspirin, for example, due to allergies (B).
3. High-dose statins in the presence of high risk (cardiovascular mortality > 2% per
year) in patients with proven coronary heart disease (B).
Class IIb:
1. Fibrates for low high-density lipoprotein levels or high triglycerides in patients with
diabetes mellitus or metabolic syndrome (B).

Recommendations for antianginal and/or anti-ischemic therapy in patients with

stable angina.
Class I:
1. Short-acting nitroglycerin for angina relief and situational prophylaxis (patients
should receive adequate instructions for the use of nitroglycerin) (B).
2. Assess the effectiveness of β,-AB and titrate its dose to the maximum therapeutic
dose; assess the feasibility of using a long-acting drug (A).
3. In case of poor tolerability or low effectiveness of β-AB, prescribe monotherapy
with AK (A), long-acting nitrate (C).
4. If β-AB monotherapy is not effective enough, add dihydropyridine AK (B).
Class IIa:
1. If β-AB is poorly tolerated, prescribe an inhibitor of the I channels of the sinus node
- ivabradine (B).
2. If AA monotherapy or combination therapy of AA and β-AB is ineffective, replace
AA with long-acting nitrate. Avoid developing nitrate tolerance (C).
Class IIb:
1. Metabolic drugs (trimetazidine MB) can be prescribed to enhance the antianginal
effectiveness of standard drugs or as an alternative to them in case of intolerance or
contraindications for use (B).

Basic medications
Nitrates
- 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
- Zofenopril 7.5 mg (preferably prescribed for CKD - GFR less than 30 ml/min)
Antiplatelet agents
- Acetylsalicylic acid tab. coated 75, 100 mg
Lipid-lowering agents
- Rosuvastatin tab. 10 mg

Additional medications
Nitrates
- Isosorbide dinitrate tab. 20 mg
- Isosorbide dinitrate aeros dose
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
- Nifedipine tab. 20 mg
AIF inhibitors
- Perindopril tab. 5 mg, 10 mg
- Captopril tablet. 25 mg
Angiotensin II receptor antagonists
- Valsartan tab. 80 mg, 160 mg
- Candesartan tab. 8 mg, 16 mg
Antiplatelet agents
- Clopidogrel tab. 75 mg
Lipid-lowering drugs
- Atorvastatin tab. 40 mg
- Fenofibrate tab. 145 mg
- Tofisopam tab. 50 mg
- Diazepam tab. 5mg
- Diazepam amp 2ml
- Spironolactone tab. 25 mg, 50 mg
- Ivabradine tablet. 5 mg
- Trimetazidine tab. 35 mg
- Esomeprazole lyophilisate amp. 40 mg
- Esomeprazole tab. 40 mg
- Pantoprazole tab. 40 mg
- Sodium chloride 0.9% solution 200 ml, 400 ml
- Dextrose 5% solution 200 ml, 400 ml
- Dobutamine* (stress tests) 250 mg/50 ml
Note: * Medicines not registered in Republic of Kazakhstan, imported under a one-
time import permit ( Order of the Ministry of Health of the Republic of Kazakhstan
dated December 27, 2012 No. 903 “On approval of maximum prices for medicines
purchased within the framework of the guaranteed volume of free medical care for
2013”).

Surgical intervention
Invasive treatment of stable angina is indicated primarily for patients with a high risk
of complications, because revascularization and medical treatment do not differ in the
incidence of myocardial infarction and mortality. The effectiveness of PCI (stenting)
and medical therapy has been compared in several meta-analyses and a large RCT.
Most meta-analyses found no reduction in mortality, an increased risk of nonfatal
periprocedural MI, and a decreased need for repeat revascularization after PCI.
Balloon angioplasty combined with stent placement to prevent restenosis. Stents
coated with cytostatics (paclitaxel, sirolimus, everolimus and others) reduce the rate
of restenosis and repeated revascularization.
It is recommended to use stents that meet the following specifications:
Drug-eluting coronary stent
1. Everolimus drug-eluting baolon-expandable stent on a quick-change delivery
system, 143 cm long. Made of cobalt-chromium alloy L-605, wall thickness 0.0032'.
Cylinder material - Pebax. Passage profile 0.041'. Proximal shaft 0.031', distal - 034'.
Nominal pressure 8 atm for 2.25-2.75 mm, 10 atm for 3.0-4.0 mm. Burst pressure - 18
atm. Lengths 8, 12, 15, 18, 23, 28, 33, 38 mm. Diameters 2.25, 2.5, 2.75, 3.0, 3.5, 4.0
mm. Dimensions upon request.
2. Stent material is cobalt-chromium alloy L-605. Cylinder material - Fulcrum. Coated
with a mixture of the drug zotarolimus and BioLinx polymer. Cell thickness 0.091mm
(0.0036'). The delivery system is 140 cm long. The size of the proximal catheter shaft
is 0.69 mm, the distal shaft is 0.91 mm. Nominal pressure: 9 atm. Burst pressure 16
atm. for diameters 2.25-3.5 mm, 15 atm. for diameter 4.0 mm. Dimensions: diameter
2.25, 2.50, 2.75, 3.00, 3.50, 4.00 and stent length (mm) -8, 9, 12, 14, 15, 18, 22, 26, 30,
34, 38. 3. Stent material -
platinum chrome alloy. The share of platinum in the alloy is at least 33%. The share of
nickel in the alloy is no more than 9%. The thickness of the stent walls is 0.0032'. The
drug coating of the stent consists of two polymers and a drug. The thickness of the
polymer coating is 0.007 mm. The profile of the stent on the delivery system is no
more than 0.042' (for a stent with a diameter of 3 mm). The maximum diameter of the
expanded stent cell is not less than 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 are 8 mm, 12 mm, 16 mm, 20 mm, 24 mm, 28 mm, 32 mm, 38
mm. Nominal pressure - not less than 12 atm. Maximum pressure - not less than 18
atm. The profile of the tip of the stent delivery system balloon is no more than 0.017'.
The working length of the balloon catheter on which the stent is mounted is at least
144 cm. The length of the tip of the delivery system balloon is 1.75 mm. 5-petal
technology for laying the balloon. X-ray contrast markers made of platinum-iridium
alloy. The length of the radiopaque markers is 0.94 mm.
4. Stent material: cobalt-chromium alloy, L-605. Passive coating: amorphous silicone
carbide, active coating: biodegradable polylactide (L-PLA, Poly-L-Lactic Acid, PLLA)
including Sirolimus. The thickness of the stent frame with a nominal diameter of 2.0-
3.0 mm is not more than 60 microns (0.0024"). Crossing profile of the stent - 0.039'
(0.994 mm). Stent 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. The diameter of the distal end part (entrance profile) is
0.017' (0.4318 mm). The working length of the catheter is 140 cm. The nominal
pressure is 8 atm. The calculated burst pressure of the cylinder is 16 atm. Stent
diameter 2.25 mm at a pressure of 8 atmospheres: 2.0 mm. Stent diameter 2.25 mm
at a pressure of 14 atmospheres: 2.43 mm.

Coronary stent without drug coating

1. Balloon-expandable stent on a rapid delivery system 143 cm. Stent material: non-
magnetic cobalt-chromium alloy L-605. Cylinder 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. Lengths: 8, 12,
15, 18, 23, 28 mm. Stent profile on balloon 0.040' (stent 3.0x18 mm). The length of the
working surface of the balloon beyond the edges of the stent (balloon overhang) is no
more than 0.69 mm. Compliance: nominal pressure (NP) 9 atm., design burst pressure
(RBP) 16 atm.
2. Stent material is cobalt-chromium alloy L-605. Cell thickness 0.091 mm (0.0036').
The delivery system is 140 cm long. The size of the proximal catheter shaft is 0.69
mm, the distal shaft is 0.91 mm. Nominal pressure: 9 atm. Burst pressure 16 atm. for
diameters 2.25-3.5 mm, 15 atm. for diameter 4.0 mm. Dimensions: diameter 2.25,
2.50, 2.75, 3.00, 3.50, 4.00 and stent length (mm) - 8, 9, 12, 14, 15, 18, 22, 26, 30, 34,
38. 3. Stent material - stainless
steel brand 316L on a rapid delivery system 145 cm long. Availability of M coating of
the distal shaft (except for the stent). The delivery system design is a three-lobe
balloon boat. Stent wall thickness: no more than 0.08 mm. The stent design is open
cell. Availability of a low profile of 0.038' for a stent with a diameter of 3.0 mm.
Possibility of using a guiding catheter with an internal diameter of 0.056'/1.42 mm.
The nominal pressure of the cylinder is 9 atm for a diameter of 4 mm and 10 atm for
diameters from 2.0 to 3.5 mm; burst pressure 14 atm. The diameter of the proximal
shaft is 2.0 Fr, the distal one is 2.7 Fr, Diameters: 2.0; 2.25; 2.5; 3.0; 3.5; 4.0 Length 8;
10; 13; 15; 18; 20; 23; 25; 30 mm.
Compared with drug therapy, coronary artery dilatation does not reduce mortality and
the risk of myocardial infarction in patients with stable angina, but increases exercise
tolerance and reduces the incidence of angina and hospitalization. Before PCI, the
patient receives a loading dose of clopidogrel (600 mg).
After implantation of non-drug-eluting stents, combination therapy with aspirin 75
mg/day is recommended for 12 weeks. and clopidogrel 75 mg/day, and then continue
taking aspirin alone. If a drug-eluting stent is implanted, combination therapy
continues for up to 12-24 months. If the risk of vascular thrombosis is high, then
therapy with two antiplatelet agents can be continued for more than a year.
Combination therapy with antiplatelet agents in the presence of other risk factors (age
>60 years, taking corticosteroids/NSAIDs, dyspepsia or heartburn) requires
prophylactic administration of proton pump inhibitors (for example, rabeprazole,
pantoprazole, etc.).

Contraindications to myocardial revascularization.

- Borderline stenosis (50-70%) of the coronary artery, except for the trunk of the left
coronary artery, and the absence of signs of myocardial ischemia during non-invasive
examination.
- Insignificant coronary stenosis (<50%).
- Patients with stenosis of 1 or 2 coronary arteries without significant proximal
narrowing of the anterior descending artery, who have mild or no symptoms of angina
and have not received adequate drug therapy.
- High operative risk of complications or death (possible mortality > 10-15%) unless it
is offset by the expected significant improvement in survival or QoL.

Coronary artery bypass surgery

There are two indications for CABG: improvement of prognosis and reduction of
symptoms. A reduction in mortality and the risk of developing MI has not been
convincingly proven.
Consultation with a cardiac surgeon is necessary to determine the indications for
surgical revascularization as part of a collegial decision (cardiologist + cardiac
surgeon + anesthesiologist + interventional cardiologist).
Table 7 - Indications for revascularization in patients with stable angina or occult
ischemia
Grade and
Anatomical subpopulation of CAD level of
evidence

Lesion of the LMCA trunk >50% with

Lesion of the proximal part of the LAD >50% with IА
Lesion of 2 or 3 coronary arteries with impaired LV IА
To improve function IB
the forecast Proven widespread ischemia (>10% of the LV) IB
Lesion of a single patent vessel >500 IC
Lesion of one vessel without involvement of the IIIA
proximal parts of LAD and ischemia >10%

Any stenosis >50% accompanied by angina or angina IA

equivalents that persist during OMT
To relieve
Dyspnea/chronic heart failure and ischemia >10% of IIa B
symptoms
the LV supplied by the stenotic artery (>50%)
No symptoms during OMT III C
OMT = optimal medical therapy;
FFR = fractional flow reserve;
LAD = anterior descending artery;
LCA = left coronary artery;
PCI = percutaneous coronary intervention.

Recommendations for myocardial revascularization to improve the prognosis in

patients with stable angina
Class I:
1. Coronary artery bypass grafting in cases of severe stenosis of the main trunk of the
left coronary artery or significant narrowing of the proximal segment of the left
descending and circumflex coronary arteries (A).
2. Coronary artery bypass grafting for severe proximal stenosis of the 3 main coronary
arteries, especially in patients with reduced left ventricular function or rapidly
occurring or widespread reversible myocardial ischemia during functional tests (A).
3. Coronary artery bypass grafting for stenosis of one or two coronary arteries in
combination with a pronounced narrowing of the proximal part of the left anterior
descending artery and reversible myocardial ischemia in non-invasive studies (A).
4. Coronary artery bypass grafting in cases of severe stenosis of the coronary arteries
in combination with impaired left ventricular function and the presence of viable
myocardium according to non-invasive tests (B).
Class II a:
1. Coronary artery bypass grafting for stenosis of one or two coronary arteries without
significant narrowing of the left anterior descending artery in patients who have
suffered sudden death or persistent ventricular tachycardia (B).
2. Coronary bypass surgery for severe stenosis of 3 coronary arteries in patients with
diabetes mellitus, in whom signs of reversible myocardial ischemia are determined
during functional tests (C).

Prevention
Key lifestyle interventions include smoking cessation and tight blood pressure control,
dietary advice and weight control, and encouragement of physical activity. Although
GPs will be responsible for the long-term management of this group of patients, these
interventions will have a better chance of being implemented if they are initiated while
patients are in hospital. In addition, the benefits and importance of lifestyle changes
must be explained and suggested to the patient - who is the key player - before
discharge. However, life habits are not easy to change, and implementing and
following up on these changes is a long-term challenge. In this regard, close
collaboration between the cardiologist and general practitioner, nurses, rehabilitation
specialists, pharmacists, nutritionists, and physiotherapists is critical.

To give up smoking
Patients who quit smoking had a reduced mortality rate compared with those who
continued to smoke. Smoking cessation is the most effective of all secondary
preventive measures and therefore every effort should be made to achieve this.
However, it is common for patients to resume smoking after discharge, and ongoing
support and advice are required during the rehabilitation period. The use of nicotine
substitutes, buproprion, and antidepressants may be helpful. A smoking cessation
protocol should be adopted by each hospital.

Diet and weight control

Currently, prevention guidelines recommend:
1. a rational, balanced diet;
2. control of caloric content of foods to avoid obesity;
3. increasing the consumption of fruits and vegetables, as well as whole grain cereals,
fish (especially fatty varieties), lean meat and low-fat dairy products;
4. Replace saturated fats with monounsaturated and polyunsaturated fats from
vegetable and marine sources, and reduce total fat (of which less than one-third
should be saturated) to less than 30% of total caloric intake;
5. limiting salt intake with concomitant arterial hypertension and heart failure.

Obesity is a growing problem. Current EOC guidelines define a body mass index
(BMI) of less than 25 kg/m2 as the optimal level, and recommend weight loss for a BMI
of 30 kg/m2 or more, and a waist circumference of more than 102 cm in men or more
than 88 cm in women, as weight loss can improve many obesity-related risk factors.
However, weight loss alone has not been found to reduce mortality rates. Body mass
index = weight (kg): height (m2 ) .

Physical activity
Regular physical exercise brings improvement to patients with stable coronary artery
disease. For patients, it can reduce anxiety associated with life-threatening illnesses
and increase self-confidence. It is recommended that you do thirty minutes of
moderate-intensity aerobic exercise at least five times a week. Each increment in peak
exercise power results in a 8-14% reduction in all-cause mortality risk.

Blood pressure control

Pharmacotherapy (beta blockers, ACE inhibitors, or angiotensin receptor blockers) in
addition to lifestyle changes (reducing salt intake, increasing physical activity, and
losing weight) usually helps achieve these goals. Additional drug therapy may also be
needed.

Further management:
Rehabilitation of patients with stable angina
Dosed physical activity allows you to:
- optimize the functional state of the patient's cardiovascular system by turning on
cardiac and extracardiac compensation mechanisms;
- increase TFN;
- slow down the progression of coronary artery disease, prevent the occurrence of
exacerbations and complications;
- return the patient to professional work and increase his self-care capabilities;
- reduce the dose of antianginal drugs;
- improve the patient’s well-being and quality of life.
Contraindications to dosed physical training are:
- unstable angina;
- heart rhythm disturbances: constant or frequently occurring paroxysmal form of
atrial fibrillation or flutter, parasystole, migration of the pacemaker, frequent polytopic
or group extrasystole, AV block of the II-III degree;
- uncontrolled hypertension (BP > 180/100 mmHg);
- pathology of the musculoskeletal system;
- history of thromboembolism.

Psychological rehabilitation.
Virtually every patient with stable angina needs psychological rehabilitation. On an
outpatient basis, if specialists are available, the most accessible classes are rational
psychotherapy, group psychotherapy (coronary club) and autogenic training. If
necessary, patients can be prescribed psychotropic drugs (tranquilizers,
antidepressants).

Sexual aspect of rehabilitation.

During intimate intimacy in patients with stable angina, due to an increase in heart rate
and blood pressure, conditions may arise for the development of an anginal attack.
Patients should be aware of this and take antianginal drugs in time to prevent angina
attacks.
Patients with high class angina (III-IV) should adequately assess their capabilities in
this regard and take into account the risk of developing cardiovascular complications.
Patients with erectile dysfunction, after consulting a doctor, can use
phosphodiesterase type 5 inhibitors: sildenafil, vardanafil, tardanafil, but taking into
account contraindications: taking long-acting nitrates, low blood pressure, exercise
therapy.

Work ability.
An important stage in the rehabilitation of patients with stable angina is the
assessment of their ability to work and rational employment. The ability to work in
patients with stable angina is determined mainly by its FC and the results of stress
tests. In addition, one should take into account the state of contractility of the heart
muscle, the possible presence of signs of CHF, a history of MI, as well as CAG
indicators, indicating the number and degree of damage to the coronary artery.
Dispensary observation.
All patients with stable angina, regardless of age and the presence of concomitant
diseases, must be registered with a dispensary. Among them, it is advisable to identify
a high-risk group: a history of myocardial infarction, periods of instability in the course
of coronary artery disease, frequent episodes of silent myocardial ischemia, serious
cardiac arrhythmias, heart failure, severe concomitant diseases: diabetes,
cerebrovascular accidents, etc. Dispensary observation involves systematic visits to a
cardiologist ( therapist) once every 6 months with mandatory instrumental
examination methods: ECG, Echo CG, stress tests, determination of lipid profile, as
well as Holter monitoring of ECG and ABPM according to indications. An essential
point is the appointment of adequate drug therapy and correction of risk factors.

Indicators of treatment effectiveness and safety of diagnostic and treatment

methods described in the protocol:
Antianginal therapy is considered effective if angina pectoris can be eliminated
completely or the patient can be transferred from a higher FC to a lower FC while
maintaining good QoL.

Hospitalization

Indications for hospitalization:

Maintaining a high functional class of stable angina (III-IV FC), despite full drug
treatment.

Information
Sources and literature
I. Minutes of meetings of the Expert Commission on Health Development of the
Ministry of Health of the Republic of Kazakhstan, 2013
1. 1. ESC Guidelines on the management of stable angina pectoris. European Heart
Journal. 2006; 27(11): I341-8 I. 2. BHOK. Diagnosis and treatment of stable
angina. Russian recommendations (second revision). Cardiovascular. ter. and
prophylaxis. 2008; Appendix 4. 3. Recommendations for myocardial
revascularization. European Society of Cardiology 2010.
Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers:

1. Berkinbaev S.F. - Doctor of Medical Sciences, Professor, Director of the Research
Institute of Cardiology and Internal Medicine.
2. Dzhunusbekova G.A. - Doctor of Medical Sciences, Deputy Director of the
Research Institute of Cardiology and Internal Medicine.
3. Musagalieva A.T. - Candidate of Medical Sciences, Head of the Department of
Cardiology, Researchанглийский
Institute of Cardiology and Internal Medicine.
русский 
4. Salikhova Z.I. - Junior Researcher, Department of Cardiology, Research Institute of
Cardiology and Internal Medicine.
5. Amantaeva A.N. - Junior Researcher, Department of Cardiology, Research Institute
of Cardiology and Internal Medicine.

Reviewers:
Abseitova SR. - Doctor of Medical Sciences, Chief Cardiologist of the Ministry of
Health of the Republic of Kazakhstan.

Indication of absence of conflict of interest: none.

Indication of the conditions for revision of the protocol: The protocol is revised at
least once every 5 years, or upon receipt of new data on the diagnosis and treatment
of the corresponding disease, condition or syndrome.

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