Treatment: strategy and tactics The main principles of the strategy to combat ND are: 1. First, emergency care, then diagnostics and planned therapy.2. Complex treatment of DN.3. Determination and elimination of the main physiological mechanisms of DN as the basis of its treatment.4. Treatment

Tactics to fight cancer Tumors, like fungi, have a self-controlled growth mechanism, their cells secrete enzymes that dissolve the proteins of surrounding tissues. In most cases, a person does not know what kind of tumor process is developing in him. Ignorance of the species

Treatment tactics After the rupture is detected, anesthesia and suturing with catgut sutures are performed (due to the fact that they dissolve). Bleeding from vaginal wounds usually stops after suturing the gap. Individual tears in the vaginal wall, small and large genital

Treatment tactics After childbirth, the doctor and midwife must examine the cervix, vaginal vaults and external genitalia in order to detect ruptures. Inspection is carried out using special vaginal mirrors. If you suspect a rupture of the perineum of the III degree

Tactics of treatment In a situation of an incipient or threatening rupture of the uterine wall, a woman needs immediate qualified medical assistance. First of all, helping a woman consists in stopping labor activity with medication. Later on, when

Tactics of management and treatment In case of a uterine rupture, an emergency caesarean section is necessary with simultaneous resuscitation to replenish blood loss. As a rule, when the uterus ruptures, the fetus almost always dies. Operation

The choice of treatment tactics includes two different in nature, but closely interrelated stages:

obtaining written consent from the patient to conduct appropriate therapeutic measures.

When it comes to a serious intervention such as abdominal surgery, these stages are relatively complex and formalized by signing the appropriate document *. However, they are an integral part of even a brief medical consultation. When the doctor simply tells the patient what he should do, and the patient follows this prescription, it implies the presence of a recommendation on the one hand, and agreement on the other.

* As the reader will see, obtaining the written consent of the patient is a prerequisite not only for a surgical operation, but also for any diagnostic or therapeutic manipulation that can harm the patient, including, for example, such safe methods as an electrocardiographic test with physical activity.

this, even if the first is not clearly substantiated, and the second is not formally fixed. Thus, making a decision about treatment tactics always involves two different processes, the failure to distinguish which is the source of often occurring difficulties.

On the one hand, some doctors believe that they “know better” and expect the patient to agree with their recommendations without hesitation and without asking for a “second opinion”. Such doctors usually feel a threat to their authority in someone else's opinion, do not like it when the patient shows curiosity, and are ready to refuse the patient if he rejects their recommendations.

On the other hand, more and more doctors see it as their job to report "naked" facts without expressing their own opinion. Such doctors state to the patient all the specific information concerning him, but they themselves do not recommend anything. It is difficult for the patient to deal with this type of physician because of their detached demeanor, unwillingness to take responsibility for the results of treatment and inability to inspire confidence in their professional competence.

Some patients are specifically looking for doctors of one of these types, recognizing the legitimacy of their approach, but now a truly competent specialist is increasingly considered one who can cope with both tasks - developing recommendations explaining their essence to the patient and obtaining written consent from him to conduct appropriate therapeutic measures.

Consider what factors the doctor should take into account when making recommendations. After that, we will discuss the process of obtaining written consent, looking at the same factors through the eyes of the patient.

Discussing the safety of treatment, we focused on two parameters that characterize it - the likelihood of side effects and their severity. The same indicators are applicable to characterize the effectiveness of the proposed treatment method. Thus, theoretically, the doctor's task when choosing treatment tactics is reduced to comparing the probability and severity of the positive impact of each potentially applicable treatment method with the probability and severity of its negative impact. How to approach this complex analysis of potential benefits and dangers? Often the matter is limited to the assessment of probability alone. However, once the results of clinical trials are available, risks and benefits can be compared using a metric sometimes referred to as experiencenym number of patients. By calculating this number, we assume that in patients in the experimental group (receiving treatment), the prognosis is better than in patients in the control group (natural course of the disease); then, to identify the benefits of this method, the required number of patients will be:

/Probability I of a good outcome in the experimental group

Let us now assume that, according to the available data, the probability of a favorable outcome in the experimental group is 3/5, and in the control group similar in all other parameters - 2/5. Then the required number of patients to identify the benefits of the chosen method will be:

This calculation shows that in order to obtain one additional favorable result, you need to use this method in five patients. The calculation is applicable for comparing different methods of treatment or for comparing the benefits of the chosen method with its dangers*.

The number of patients in whom a given treatment method is used, necessary for its adverse effects (complications of treatment) to manifest itself, is calculated in a similar way:

* When these numbers are used to compare different treatments, it should be taken into account that the duration of the use of different methods in the experiments could not be the same. However, if it is known how long the treatment lasted in each case, this discrepancy can be taken into account by taking a comparable basis for comparison. Note. ed.

The likelihood of complications in the control group

If, say, a certain complication is noted in two out of a hundred treated patients (from the experimental group) and only in one out of a hundred untreated patients (from the control group), then the required number of patients to identify the danger of this complication using the selected method will be:

_____1 _______

2/100 - 1/100 = 100

Two parameters can be calculated in parallel: the number of patients in whom a given treatment method needs to be applied in order to obtain one additional positive result and one additional negative result. For example, you can calculate the number of patients who need to be prescribed a particular drug to prevent one myocardial infarction, and the number of patients in which this drug will cause one additional complication, such as a stroke. If the first number is 5 and the second is 100, then the probability that the treatment will benefit the patient is 20 greater than the probability that it will cause harm. Often this is all that is required to make recommendations, especially if you consider stroke and myocardial infarction as equally dangerous outcomes expected at about the same time.

However, the described process is not as simple as it seems. Doctors often have to rely not on the objective results of clinical trials, but on their own, sometimes very approximate estimates of the likelihood of a particular outcome (estimated probability). We must also take into account the fact that the same outcome of the disease means different things for different patients, as well as the timing of different potential outcomes.

Estimated probability implies a more or less reasonable assumption, which is based both on the literature data on the effect of a particular treatment method on different groups of patients, and on information collected about a particular patient.

Real Consequences is the outcome of the disease from the point of view of the patient. Much depends on individual characteristics: it is known that the same outcome is perceived differently by different people, whether it is about losing a leg, blindness, or even a stroke.

To formulate our recommendations, we must combine the estimated probability with the real consequences. This can be done quantitatively using a method called decision analysis *, however, they are more often limited to a purely qualitative comparison, usually almost unconscious, without considering the individual components of the solution.

Whose point of view is more important - our own or the patient's? It is desirable that our recommendations take into account the opinion of the patient as much as possible, although this is not easy. And yet it is the patient who has the decisive word here - he gives written consent to the implementation of our recommendations.

So, in the process of developing treatment recommendations and obtaining written consent, there are two sources of uncertainty - the estimated probability and the real consequences. Let us now turn to the process of obtaining written consent. First, we will consider the requirements for this process, and then we will discuss how to avoid many of the mistakes that await the doctor in the course of performing the dual task of developing treatment recommendations with an explanation of their essence to the patient and obtaining written consent from him to conduct appropriate therapeutic measures.

WRITTEN AGREEMENT

In accordance with the law and accepted professional standards, a patient who gives written consent to conduct diagnostic and treatment measures must:

* The decision analysis methodology is as follows. A certain probability score is assigned for each outcome (from zero to one) and the outcome of treatment itself (death - zero, complete recovery - one) and then these scores are multiplied in pairs. The products are added together - the resulting amount characterizes the expected practicality this treatment method. Using these values, different treatment methods can be compared. Note. ed.

Be able to make a decision;

Have sufficient information to make a decision;

Be free to make decisions*.

So, the first condition - the patient must be able to make decisions. It is not only about capacity in the legal sense. The patient must understand the essence of the matter and delve into all the details. As defined by the Presidential Commission on Bioethics, the ability to make decisions requires a set of enduring values ​​and goals, the ability to understand and communicate information, and the ability to justify and reflect on choices. Thus, we are talking about the fact that the patient must have sufficient intelligence to make his choice and report it, process the information received, assess the situation and its consequences for his own life. In other words, he must be involved in the intellectual work necessary to make a decision. Often this stage takes little time, since the patient is initially considered capable of making decisions, unless there is clear evidence to the contrary.

Assuming that the patient is able to give written consent to treatment, we must provide him with all the information necessary for this.

* In domestic medical practice, it is customary to confine ourselves to an entry in the medical history of the type “the patient is familiar with the essence of the upcoming intervention, consent has been obtained.” Since the concept documentary evidencefull awareness patient about the essence of his upcoming medical intervention or diagnostic test is new for Russian doctors, we consider it necessary to give an example of a document that every patient in a US clinic must sign before conducting one of the safest diagnostic tests - an electrocardiographic test with physical or drug stress. The form of the document adopted in the clinics of the University of California at San Francisco is used. Due to lack of space, the text is given with some abbreviations.

CONSENT TO CARRYING OUT ELECTROCARDIOGRAPHIC TEST WITH PHYSICAL OR MEDICATIONAL LOAD

I will have an examination that includes an electrocardiogram we are during physical activity. This study is being carried out to study activity of the heart. Recording an electrocardiogram during exercise load in some cases allows you to identify the features of cardiac activity sti that do not appear at rest.

To record an electrocardiogram, they will put wires (electrodes) on my limbs and on my chest. Then I have to walk on a treadmill or pedal a special bicycle. The load will be post.gradually increase until the heart rate reaches a certain level or until the need arises to stop the load for a different reason.

For proper treatment, I will have the blood supply of the heart examined during load time. If the exercise test is not enough for this, then I will undergo a drug test. To do this, dipyridamole, dobutamine, or another drug will be injected into the vein to create conditions for stressing the heart. As with the exercise test, electrodes will be applied. Then they will inject the drug into my vein atincreasing dose until sufficient effect is achieved or until the full dose has been administered. At this time, one of the methods will be additionally used to “see” the heart: it will be an isotope or ultrasound examination. The purpose of these methods is to assess the effect of stress on the blood supply to the heart or its function.The study may be complicated by cardiac arrhythmias (irregular lar contractions of the heart), a sharp increase or decrease in blood pressure, dizziness, shortness of breath, a feeling of lack of air. To reserious complications of my upcoming procedure include severe ser diarrhoea, which can lead to death. All will be accepted necessary precautions, which include monitoring of heart rate and blood pressure before, during and after the study. Emergency equipment and medicines will be at the ready. The study will be prepareda specialist or a nurse under the direction of a physician, I understood all of the above. The doctor answered all my questions. I give my voluntary consent to the study.Signature:

Theoretically, the doctor is obliged to explain to him the main stages through which he himself went through before formulating his recommendations. As a result, the patient receives all the necessary information and freedom of choice. It is up to doctors and lawyers to decide what kind of information is necessary and sufficient. Three standards are used in American courts. Initially (in some states this practice still exists) professionally orientedmove, according to which the doctor must tell the patient what his colleagues, who are in good repute, tell their patients. Later, most lawyers began to use the standard reasonable person(also called objective): the doctor is obliged to report everything that a "reasonable person" who happened to be in the patient's place would like to know. Recently it has been used and subjective, a patient-specific approach that requires the provision of all the information that he wants to receive.

Considering the inconsistency of all these approaches and the difficulty of fulfilling their conditions, one can understand how difficult it is sometimes for the doctor to determine what kind of information the patient needs. Usually this problem is solved in the following way: the doctor reports only the information that he used to compare different treatment options and make final recommendations. This amount of information, combined with answers to the patient's questions, seems to be a reasonable compromise. In particular, the information necessary for the patient should include the following mandatory information:

rationale for treatment: prognosis in its absence, prerequisites for using the recommended treatment method;

the main expected results of treatment and a discussion of those characteristics of the patient that may affect the result;

the main hazards of treatment, including the likelihood, severity and timing of possible side effects;

discussion of alternative therapeutic methods.

This information allows the patient to follow the course of medical thought. A description of the main benefits and potential risks of the proposed treatment gives him the opportunity to form his own opinion about the likelihood and severity of certain adverse effects. Discussing alternative therapies allows the patient to weigh the pros and cons of their use.

Having received the necessary information, the patient should be able to freely use and freely make decisions. The latter means the choice of a therapeutic method is the prerogative of the patient. Freedom of choice, that is, the absence of coercion, also implies that he must receive information in such a form that would exclude to the maximum extent both a one-sided presentation of facts and hidden or even unconscious attempts to influence the decision being made. The absence of coercion means freedom from threats, including the threat of termination of medical care. If the decision of the patient is unacceptable for the doctor, the latter is obliged to offer an alternative source of medical care, if, of course, it can be provided legally. Thus, written consent implies the ability to make choices, the possession of the necessary information and freedom of choice.

When a doctor makes recommendations, and the patient is faced with a choice, a number of medical errors are possible. Problems are most prominent in the course of obtaining written consent, so it is convenient to use this process to analyze potential deviations from the right path. First of all, we will proceed from the fact that the patient is competent to make decisions, and we will begin with obtaining the necessary information for him. Let's discuss how much the doctor's and patient's ideas about the probability and result differ, how the third factor influences the decision, which we will call attitude towards risk We then turn to freedom of choice and look at how clinicians consciously or unconsciously try to influence patient choices. Finally, we will return to the ability of the latter to make """ decisions and analyze where an incorrect interpretation of it can lead.

Estimated Probability

The subjective assessment of the probability of a positive or negative result of treatment, both in the case of the doctor and the patient, is often determined by how easy it is for them to imagine this result. The likelihood of negative outcomes is often replaced by the ability to imagine them. If a doctor has just died a patient on the operating table, and in another patient a diagnostic examination has provoked serious complications or a side effect of a drug, then it is quite understandable that he will tend to overestimate the likelihood of such situations. In addition, many doctors have a superstition that successes and failures go in stripes: sometimes you are lucky, sometimes you are not lucky. The patient is also inclined to evaluate the probability of the result, based on the liveliness of the idea of ​​it. If a friend or relative has died of lymphogranulomatosis or heart failure, it is easier for the patient to analyze the risks and benefits of treatment, but at the same time, he is likely to overestimate the possibility of a poor outcome.

It is usually difficult for a person to estimate the likelihood of an event. If this probability is actually below 1-2%, it is usually grossly overestimated or underestimated. For example, both doctors and patients may overestimate the likelihood of death from minor surgery or life-threatening complications from commonly used drugs. Conversely, they may not consider such cases at all as too unrealistic and too terrible to think about.

How to make the assessment of the doctor and the patient more accurate? For this, several methods are used.

Calculation experimental number of patients allows you to present research data in a visual form. Consider this example: with aspirin prophylaxis, one additional case of hemorrhagic stroke per 2,000 apparently healthy middle-aged men is expected, while myocardial infarction can be prevented in one case in 100; it does not take much effort to comprehend information about these rare events when it is presented in this form.

When it comes to a small risk, not exceeding 1-5%, it is more convenient to calculate chance, not a probability. So, instead of a probability of 2%, we can talk about a chance of 1:49 (or rounded 1:50). The difference between the probability 2% And A% not easy to feel; comparing the odds of 1:24 and 1:49 makes the difference clearer.

A widely used way of evaluating rare events is to compare the risk associated with them with the risk that surrounds us in Everyday life. Thus, doctors often use, and sometimes abuse, comparing the probability of an event with the probability of "getting hit by a car." If such an analogy correctly reflects the situation, then it is useful. However, the physician must be aware that the risk of death in a car accident or death from acute myocardial infarction, although quite high, is still extended in time, while the proposed treatment may pose an immediate threat to life.

Thus, one of the most common mistakes of doctors and patients is unrealistic ideas about the likelihood of a particular outcome. It is necessary to help the patient understand the figures reported to him and compare them with his own life experience, so that he estimates the probability more accurately.

Realconsequences

As already mentioned, the real consequences are the outcome of the disease in the assessment of the patient. An important factor, especially when making difficult decisions, is the acceptability of life with varying degrees of disability. The choice between chronic hemodialysis and kidney transplantation, medical treatment of coronary heart disease and coronary artery bypass grafting, chemotherapy and symptomatic treatment of metastatic cancer depends on how the doctor and patient view various forms of disability.

Some results of treatment seem absolutely terrifying to both the doctor and the patient; in this case, there may be a reassessment of their severity, and in some cases, their probability. Life without a leg, with a colostomy, or after a mastectomy seems unbearable to some. Fortunately, the patient's exaggerated fear is often not so difficult to deal with if asked to elaborate on the fear. Talking to other people who are living happily and productively after a leg amputation, colostomy, or mastectomy can be very helpful for the patient and turn their fear into a very realistic concern.

In addition to different views on the outcome of treatment, doctors and patients often share an unequal understanding of the time factor. For a doctor, a year of a patient's life may mean just half as much as two years. However, for the patient, this first year is much more important than the second, especially if it allows you to put your affairs in order, stay with family and friends, and make a long-planned trip. In addition, patients may rightly be more interested in the quality rather than the quantity of life remaining. A long life in the hospital, full of suffering, is perceived as significantly less valuable than a short period of active work or play. Thus, the results of treatment and the time factor can be perceived by doctors and patients in completely different ways. Underestimation of these differences by a doctor is fraught with serious errors in making decisions about treatment tactics.

Risk attitude

Ideally, the doctor's recommendations are based on the estimated likelihood of a particular outcome and the real consequences of the proposed treatment. If these factors speak in favor of this treatment method, then theoretically the doctor should recommend it. Often, however, the doctor's recommendations and the subsequent decision of the patient are influenced by the attitude of both of them to the risk.

Physicians usually declare their rational attitudenii to risk, about insensitivity to emotions. In other words, they try to recommend a particular treatment method only when the likelihood of a favorable result outweighs the risk of possible complications*. In fact, few people (and doctors are no exception) are so rational that they do not fear rare but catastrophic events. Most buy all kinds of insurance to protect themselves from major losses, regardless of the inevitable costs in the form of insurance premiums. This behavior is caused by the unwillingness to take risks. On the other hand, in certain situations, many seek risk. They are ready for the inevitable small losses if they receive in return at least a minimal chance of a big win, even if the mind speaks against such a decision. Proof of this is the popularity of lotteries and gambling. Most people, at the expense of rational calculations, tend to avoid risk or, conversely, take a risk, depending on the circumstances.

Comparable to insurance and the lottery are the widespread clinical situations in which a doctor or a patient is clearly irrational in their attitude to risk. Failure to recognize such cases is a source of serious errors. Patients tend to avoid risk if the situation is beyond their control and is associated with a low but tangible probability of a very severe outcome. So, most people are afraid of plane crashes much more than car accidents. Likewise, many patients and non-surgeons are wary of surgery, regardless of the risk involved. Low but tangible likelihood of such outcomes,

* Rational attitude to risk means that the doctor quantifies different treatments by calculating them practicality, and stops at the most practical option. Note. ed.

such as death on the operating table or postoperative pulmonary embolism may prompt the patient to refuse surgery. He, like a non-surgeon, will often prefer drug treatment that is easier to control and does not threaten with rare, but very terrible consequences. In other words, both physicians and patients are at times risk-averse because of the so-called insurance effect.

It happens that the uncertainty (whether an event will occur? if so, when?) is completely unbearable for the patient and for the doctor. However, the doctor can help the patient be less afraid of risk. To do this, you need to create in the patient the feeling that he, at least partially, controls the situation. For example, if you explain to the patient that early activation reduces the risk of pulmonary embolism, which means that after surgery you need to quickly move into the category of "walkers", the influence of the insurance effect will decrease. A patient who quits smoking or loses weight before surgery not only reduces the risk associated with the operation, but also actively participates in the treatment process, which is now partly under his own control. Some patients admit that risk aversion leads them to prefer the "status quo" to an unknown treatment outcome. Naturally, to avoid risk is the full right of the patient. Individuals vary greatly in their exposure to the insurance effect. Some patients consciously choose forms of treatment that are beyond their control but are associated with a lower likelihood of severe complications. This allows them to evade responsibility for participating in the treatment process, which sometimes requires a person to change established behavioral stereotypes. Thus, two people with the same chance of a certain outcome may, based on their risk attitude, choose different treatments.

Another widespread situation in which neither doctors nor patients remain indifferent to risk is the rapid deterioration of the patient's condition. When the disease progresses, and the treatment does not bring the expected result, patients become prone to gambling, risky decisions. Doctors and patients, like basketball players, who feel that the game is running out of time, often "hurry to shoot." This athletic analogy is apt to explain many heroic endeavors with little chance of success. Both doctors and patients will hardly give up trying to change the situation if there is at least a minimal hope.

In the current medical system in the United States, patients who are willing to take risks usually have every opportunity to do so. It is too difficult for a doctor alone to resist their demands. Professional norms, the traditions of the medical institution, the opinion of colleagues are the means to help weaken this lottery effect.

Thus, errors in the development of treatment tactics are often due to the difficulty in assessing the likelihood and severity of the intended outcome, as well as an irrational attitude to the risk of complications. Now we will see that errors are also associated with the method that the doctor chooses to communicate the necessary information to the patient. So, let's turn to the problems that arise when making decisions for patients.

freedom of choice

Although open threats to not provide medical care to the “naughty” are easy to recognize and ward off, communicating information to the patient in a form that does not restrict his freedom of choice is an extremely difficult task. An element of coercion is always present when the doctor presents the facts one-sidedly, so that the patient does not have a complete picture of what is happening. The doctor can get carried away by visualization and present the facts in such a frightening way that the patient will have an unjustified feeling of fear of the disease or a specific treatment method. Thus, emphasizing the real, albeit very low, probability of contracting AIDS during a blood transfusion, one can force the patient to refuse a surgical operation. Similarly, the small risk of duodenal ulcer perforation can be used to obtain consent for surgical treatment of this disease.

Everyone knows half empty effect- half full glass: the physician may emphasize either a 5% chance of death or a 95% chance of survival. The decision of the patient largely depends on what exactly he will highlight. Although it is difficult to get rid of this effect completely, it can be minimized by presenting the facts in both ways, for example, first emphasizing the possibility of death, and then the possibility of healing. In addition, sometimes it is useful to ask the patient to tell what exactly he understood from the information communicated to him. This will make it easy to determine whether he sees "glass half full" or "half empty", and then draw his attention to the ambiguity of the situation.

The described effect depends not only on our words, but also on our tone. Dispassionate, without pauses, enumeration of facts usually gives the patient the impression of a doctor's high professionalism and his confidence in what has been said, but does not reflect the complexity of the task facing the doctor and the patient. In addition, doctors usually speak more confidently about the doses of drugs, about the ways of their administration, etc., than about the appropriateness of using a particular treatment method. "We would like your agreement to administer 60mg intravenous adriamycin once every three weeks" sounds much more impressive than "we think it's worth trying to treat you with adriamycin." It is difficult to completely get rid of coercion. In fact, those physicians who are most likely to establish productive interactions with patients are the most likely to use their influence for subtle coercion more often than others.

Having discussed with the patient the likelihood of a particular outcome of the disease in its natural course, the benefits and possible dangers of treatment, giving him the necessary and sufficient information in a form that excludes coercion, the doctor, as a rule, convinces the patient of the correctness of his recommendations. Sometimes doctor and patient at least agree on what they disagree on. However, at times it can be difficult for a doctor to understand why a patient refuses a given treatment or insists on some particular variant of it. In such cases, it is useful to revisit the patient's ability to make decisions.

Ability to make decisions

If the patient was initially considered capable of making decisions, then this ability cannot be denied him, because the course of his thoughts is incomprehensible, and the choice he made does not suit us. Sometimes the choice of an adult seems illogical, but it can be based on a well-established system of views, for example, religious ones. However, if the doctor has doubts about the patient's ability to make decisions, one must be able to move on to the difficult process of assessing it. The ability to understand is clearly impaired in people with clouded consciousness. However, understanding requires not only a clear mind and the ability to concentrate. Often we judge understanding by the sustainability of the decisions we make. When doubts arise, the stability of the patient's decision should be tested by asking him the same question after a while. If the patient changes his choice every few hours, this usually indicates that his ability to make decisions is seriously impaired.

As for the ability to rationally use information, it may suffer due to a significant weakening of attention, intelligence or memory. These abilities of the patient must be checked from the very beginning by asking him to retell in his own words what he heard from the doctor. Naturally, a clear statement of the necessary facts is required of the latter. You should also make sure that the patient understands what he actually agrees to; to do this, you need to ask what he thinks will happen when he gives his consent. The ability of the patient to correctly assess the situation and its consequences is more difficult to verify, but questions like “what kind of illness do you have?” or “what do you see as the meaning of the operation?” often help to identify people with poor decision-making ability.

The level of assessment of the situation and its consequences can first be clarified by simply asking the patient what most influenced his decision to resort (or not to resort) to this type of medical intervention. If the patient gives arguments like “I want to get rid of the pain” or “this operation is too dangerous”, then he adequately assesses the situation.

Assessing the patient's ability to make decisions can sometimes be very difficult, and in case of doubt, the doctor may need to consult with colleagues or even with lawyers. When this ability is present, as it usually is, it is useful to apply the method known as judgment analysis.

Analysis of judgments helps to understand the situation when it is difficult to understand the decision of the patient. There are two widespread types of impairments in judgment, and it is the clinician's responsibility to recognize them.

First, there may be cases when the choice that the patient makes at the moment does not correspond to his past behavior or his known views. A woman who requires an amniocentesis to determine whether a fetus has Down's disease, but who at the same time advocates a total ban on abortion, may either rely too much on a favorable prognosis or be oblivious to her inconsistency. Often, a simple clarification helps to cope with such inconsistency in decision-making: “On the one hand, you insist on an amniocentesis, and on the other hand, you are not going to have an abortion if Down's disease is detected. Explain, please, the course of your thoughts. Questions of this type can cause the patient to reconsider his conclusions. Ultimately, patients have every right to be illogical and give birth to children with Down's disease, but the doctor is obliged to recognize ambiguous situations, not to go along with the patient, but to try to help him make an internally consistent decision.

The second common cause of incorrect judgments is related to the peculiarities of the mental state of the patient, which prevent him from properly focusing on making a decision. Anxiety and depression are common causes of absent-mindedness and inadequate assessments. Although these conditions do not usually render the patient incapable of making decisions (and should not be considered criteria for incompetence), they may interfere with the patient's ability to hear what the doctor has to say, process information, and make judgments. When there are problems caused by emotional factors, it is often more useful to put aside the question of the final decision and pay attention to the mental state of the patient. Correction of the anxiety-depressive state will help the patient to focus and fully use their ability to make choices.

According to the method of analysis of judgments, the patient's ability to comprehend information is closely related to how and when it is communicated to him. A woman who has just found out that she has breast cancer is usually not ready for immediate decisions. It takes time to comprehend the new reality and the subsequent choice.

When the patient's decisions seem meaningless, you need to make sure that he correctly understood the information. To do this, it is not enough just to repeat the basic information to him - it is necessary to find out what prevents a person from perceiving and comprehending them. Often the patient can be helped with questions like “what do you think will happen next?” or “what are you most afraid of?”. Such questions often make it possible to understand what exactly frightens the patient and does not allow him to perceive what he hears.

Sometimes patients are not able to overcome their horror of pain, before being connected to an artificial respiration apparatus, to get rid of analogies with a relative who died during an operation. To help the patient form a judgment that reflects his true intentions, it is useful to understand the course of his thoughts. For example, patients often have false associations of this kind: "If I have a lot in common with the name, then I will respond to treatment in the same way as he does." If a friend who has taken this drug develops a peptic ulcer or impotence, then the patient can expect the same for himself. The identification of such associations allows one to eliminate the problem by slightly modifying the proposed method of treatment, taking additional precautions, or simply explaining to the patient what is the peculiarity of his case.

It is even more difficult with patients who confuse cause with effect and believe, for example, that the cause of a poor outcome may be not the disease itself, but the means of its treatment. The line of reasoning here might go like this: “My mother died six months after she started taking blood pressure medication. So the same thing is happening to me." Such patients, who do not understand how their judgments are devoid of logic, are the most difficult to help. Usually they are deaf to all arguments of reason. Their persistent prejudice can sometimes be overcome either by bringing in other family members to the conversation, who will remind you how seriously ill the mother was before prescribing the notorious antihypertensive drug, or by persuading them to start with a low dose to avoid side effects and imbued with confidence in the proposed treatment method.

So, the process of developing treatment tactics includes two independent, but closely related stages: the development of medical recommendations and obtaining written consent from the patient for appropriate therapeutic measures. Errors caused by underestimation of each of the stages are widespread in medical practice. The immediate cause of an erroneous decision may be the difference in assessments by the doctor and the patient of the likelihood and significance of a particular treatment outcome; sometimes the source of error is the unequal attitude to risk in the doctor and the patient.

Another source of error can be the wrong way of communicating the information the patient needs to make a decision. Finally, despite the sufficiency of information and complete freedom of decision, some patients are simply unable to adequately perceive the information received. The doctor must be able to recognize such situations and help the patient to fully apply his abilities.

Making decisions about treatment tactics is a difficult process. It is impossible to achieve complete independence in decision making and a perfect understanding of the situation. Therefore, the patient is often tempted to raise his hands up and rely entirely on the opinion of the doctor. However, do not rush to the conclusion that the patient does not want to participate in the decision - try to still involve him in cooperation. Having done this, you will be surprised to find how the patient really strives for it. Fortunately, no special art is required here. The main thing for the doctor is to calmly state his recommendations, justify the choice of this treatment method and report on the main expected results and possible dangers. Then you need to answer the questions of the patient. Despite the inevitable difficulties involved in making a decision, it does not take much time and attention to significantly improve the results of this process.

Good decisions are not a guarantee of a good result, but they provide a chance for success and a basis for an unbiased assessment of the results if the latter are worse than expected. However, good decisions mean little if they are not implemented correctly. Therefore, now it is time to pay attention to the next stage, namely, the implementation of therapeutic measures.

Below are guidelines from the US National Cancer Institute.

Stages 1 and 2

If the tumor is highly or moderately differentiated, and the pathological process is at the stage of development 1a or 1b, it is enough to treat most patients. In this case, the scope of the intervention is hysterectomy, bilateral salpingo-oophorectomy and excision of the omentum. In addition, the surgeon should take pelvic and abdominal peritoneal biopsies, pelvic and para-aortic lymph node biopsies, and peritoneal washings. If we are talking about the treatment of a young patient who wants to maintain the ability to endure and give birth to a child, a unilateral salpingo-oophorectomy can be performed, however, with this decision there is some chance of a relapse.

If we are talking about the treatment of poorly differentiated tumors or ovarian cancer at stage 1c, the chance of cancer recurrence after surgical treatment is 30%. In the course of large-scale clinical trials, doctors have shown good results in the following approaches to the treatment of such pathologies:

• Intraperitoneally P-32 or radiotherapy;
• Conducting a course of systemic chemotherapy based on monotherapy with platinum preparations or in combination with alkylating agents;
• Platinum-based systemic chemotherapy in combination with paclitaxel.

Stages 3 and 4

The standard of care for patients with stage 3 and 4 ovarian cancer is a combination of surgery and course (for patients with stage 4 cancer, the prognosis is much less favorable). At the 4th stage of the development of the disease, the effectiveness of surgery is not too high, however, in most cases, the main number of malignant cells are located within abdominal cavity, and surgical intervention is one of the tools to contain the pathological process and control it.

Introperitoneal (intraperitoneal) chemotherapy.

The pharmacological substantiation of this variant of drug administration in the treatment of these types of cancer was established in the late 70s - early 80s of the last century. Several drugs have been studied simultaneously, however, the results that have attracted the most attention have been obtained using cisplatin and combinations with it. Most often, a positive effect was observed with small sizes tumors (less than 1 cm). In the 1990s, randomized trials were conducted to evaluate the effectiveness of the intraperitoneal route of administration of the drug cisplatin compared with its intravenous administration. It was found that intraperitoneal administration has a huge advantage, namely, cancer cells that are located directly in the abdominal cavity receive this drug in a higher concentration. However, do not forget about a significant number of side effects:

• From the side of the catheter - infection, blockage, damage to the intestine with a needle;
• General - pain in the abdomen of a significant degree, severe nausea and vomiting.

Often, side effects force patients to insist on early termination of treatment. Despite all this, it is intraperitoneal chemotherapy that helps many patients prolong life.

This treatment is carried out exclusively with the normal functioning of the kidneys, since it is very toxic.

Treatment Options for Stage IV Patients

Cytoreductive surgery

The feasibility of using cytoreductive surgery has been studied for a long time. Conducted global clinical studies have shown an increase in the survival rate in a group of patients who underwent cytoreductive surgery after completing four cycles of exposure to cyclophosphamide and cisplatin compared with a group of patients who received chemotherapy but did not undergo surgery. When cytoreductive surgery is performed in combination with the further administration of first-line chemotherapy drugs, in most patients it is possible to achieve complete tumor regression with normalization of all tumor markers. Nevertheless, the results of five-year survival of patients with stage III ovarian cancer are about 25%, and stage IV, unfortunately, is not higher than 10%.

Systemic chemotherapy

The first line drug in the treatment of ovarian cancer is cisplatin or its second-generation counterpart, carboplatin, given either in combination with other drugs (eg, taxane) or separately. The efficacy of cisplatin is approximately 60% in patients who have not previously received chemotherapy, and about 30% in those who are undergoing repeat chemotherapy. The five-year survival rate in the first group is about 16%. Carboplatin Recently, it has been used more and more often, since it has a lower degree of toxicity in comparison with cisplatin with the same degree of activity.

The most popular combinations of drugs based on platinum are regimens cisplatin + cyclophosphamide And carboplatin + cyclophosphamide.

Taking into account the fact that drugs containing platinum play an important role in the treatment of ovarian cancer, the development of a third-generation platinum derivative looks very promising today - oxaliplatin. These studies have already proven the activity of the drug both in combinations and in monotherapy, and limited cross-resistance of the drug with cisplatin and carboplatin was revealed. It was also noted that the effectiveness of the third generation drug in comparison with the first generation does not differ significantly, however, the degree of toxicity of the combination oxaliplatin with cyclophosphamide significantly lower: the number of required blood transfusions decreased, pronounced leukopenia and nausea were observed much less frequently.

It is impossible not to mention a number of new drugs, among which the most studied and widely used are taxanes, namely paclitaxel. Clinicians note its high activity both in patients with relapses and in patients who have not previously received any treatment. According to studies, the replacement of cyclophosphamide with a combination of paclitaxel and cisplatin leads to a significant increase in the frequency of all objective effects, as well as a lengthening of overall and disease-free survival. Today, the combination of cisplatin + paclitaxel is considered the standard for induction chemotherapy in the treatment of malignant ovarian pathologies, however, its widespread use in Russia is limited due to the high cost of the course of treatment.

Docetaxel, the second taxane derivative, also has a high level of activity in ovarian cancer: the effectiveness of this drug in combination with drugs containing platinum is 83% during induction therapy. It is noted that in this case, combinations with the inclusion of docetaxel have a lower degree of neurotoxicity; however, comparative studies of the toxicity and efficacy of docetaxel are not yet available. That is why today in all official prescriptions and recommendations, paclitaxel is the drug of choice.

In the event of a relapse of the disease, the likelihood of a response to repeat chemotherapy based on drugs containing platinum depends on the length of the period during which the drug was not used. If this period exceeds half a year, then many clinicians prefer to re-treat by switching patients from cisplatin to carboplatin, or vice versa. However, those patients whose pathology progresses under the conditions of the initial intake of platinum drugs, as well as those in whom recurrence of ovarian cancer develops within six months after such treatment with platinum drugs, very rarely respond to continued treatment with these drugs. It is then believed that their disease is resistant to platinum. For such patients, paclitaxel is often used as the active drug. This drug, in general, is well tolerated, however, it has a number of side effects, such as alopecia, neuropathy and myelosuppression.

Clinical studies conducted in 2003 demonstrated a beneficial effect of the combination of paclitaxel and platinum-containing products on progression-free survival and overall survival in patients with recurrent platinum-sensitive ovarian cancer. Most often, paclitaxel was combined with carboplatin.

Gemcitabine is another promising second-line chemotherapy drug. Its effectiveness as a first-line drug is about 23%, while in combination with cisplatin it is 70%. When conducting chemotherapy with a combination of topotecan and paclitexel, it is possible to achieve overall effect 29-46%.

Characteristics of patients requiring second-line chemotherapy:

• Recurrent ovarian cancer potentially sensitive to platinum-containing drugs. In this group, clinicians include patients who have achieved complete regression of the cancer during chemotherapy with first-line drugs, including drugs containing platinum, in whom progression occurred no earlier than six months after stopping treatment;
• Resistant ovarian cancer. In this group, clinicians include patients who achieved complete regression of the cancer during chemotherapy with first-line drugs, including drugs containing platinum, in whom the progression of the pathology occurred earlier than six months after stopping treatment;
• Persistent ovarian cancer. This group includes patients who achieved partial tumor regression during chemotherapy with first-line drugs, including drugs containing platinum, but who retained elevated levels of CA-125 or have some detectable manifestations of the malignant process, for example, during second look surgery;
• Refractory ovarian cancer. This group includes patients who do not show the effect of chemotherapy with first-line drugs, including drugs containing platinum, as well as those patients who have progression of the pathology against the background of chemotherapy with first-line drugs.

The arsenal of drugs that are used for second-line chemotherapy is very large. This is eloquent evidence that in fact none of them allows you to achieve long-term remissions. The effectiveness of second-line drugs varies in the range of 12-40% with an average life expectancy of the patient from 9 months to a year.

Unfortunately, many years of experience show us that chemotherapy with second-line drugs, although it allows to some extent control the symptoms of the disease in most patients, including those who have shown resistance to platinum drugs, increase the time period before progression and the total life expectancy in some patients, but is not capable, alas, of leading to a cure. In fact, second-line chemotherapy is a palliative measure.

Currently, the search for new approaches to the treatment of patients with ovarian cancer, such as the possible use of vaccine therapy and gene therapy, is being closely conducted. However, given the chronic course of ovarian cancer, there is some hope that latest methods treatments will provide long-term stabilization of the pathology under conditions of minimal toxicity and good general condition of patients.

Consolidation and/or maintenance therapy

Supportive therapy is understood as giving the patient additional courses of chemotherapy, more than six standard ones. Thus, it is supposed to delay or even prevent the recurrence of pathology. To clarify the feasibility of such therapy, a clinical study was conducted. Patients who achieved complete regression of the cancer, after completing six courses of standard chemotherapy with paclitaxel and platinum derivatives, received either three or twelve additional courses of paclitaxel every 3 weeks. When observing patients, it turned out that maintenance therapy can be useful in cases of high sensitivity of tumors to chemotherapy. However, the advisability of using maintenance therapy is still the subject of much controversy.

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Catad_tema IHD (ischemic heart disease) - articles

Tactics of treatment and management of patients with stable angina pectoris

V.P. Lupanov, Doctor of Medical Sciences, Institute of Clinical Cardiology named after A.I. A.L. Myasnikova RK NPK Ministry of Health of the Russian Federation, Moscow

Ischemic (coronary) heart disease (CHD), which develops as a result of atherosclerosis of the coronary arteries, is the leading cause of disability and mortality in the working population worldwide. Mortality and incidence of non-fatal myocardial infarction is 2-3% per year. In addition, the disease is accompanied by a significant decrease in the quality of life of patients.

In Russia, the prevalence cardiovascular diseases and coronary artery disease is growing, and in terms of mortality from them, Russia is one of the first places in the world, which makes it necessary for doctors to use modern and effective methods its treatment and prevention.

Patients with angina pectoris, including those who have already had myocardial infarction, constitute the largest group of patients with coronary artery disease. These explains the interest of practitioners in the proper management of patients with angina pectoris and the choice of optimal methods of treatment.

Treatment of IHD often presents great difficulties, which determines the relevance of the problem. Difficulties in treatment are due to both the variety of clinical forms of coronary artery disease, stages of the disease, its course options, complications, and the large number of drugs, the effectiveness of some of them is doubtful, is of an advertising nature and is not confirmed by reliable clinical data.

IN last years cardiology is increasingly moving towards the standards of ''evidence-based medicine'', according to which new ways of detecting and correcting diseases are subjected to rigorous ''selection'' in rigorous clinical trials with a large number of participants and with careful statistical analysis. Only those therapeutic interventions that have convincingly proved their effectiveness are recommended for universal use.

When evaluating methods of treating coronary artery disease, they increasingly proceed from a strategy based on interventions that improve the prognosis, and then tactical tasks are considered - improving the quality of life of the patient, reducing angina attacks and myocardial ischemia.

Basic principles of therapy for patients with chronic coronary artery disease

The treatment of patients should be comprehensive and include: impact on the patient's risk factors and lifestyle, including neuropsychological status, physical activity, concomitant diseases. It is necessary to use individually selected treatment regimens, taking into account the effectiveness of a single and daily dose; while taking into account the possibility of side effects of drugs, the development of tolerance, withdrawal syndrome. Be sure to carry out dynamic monitoring of the effectiveness and safety of treatment and adjust it in a timely manner (cancellation or replacement of the drug, dose change). Treatment with antianginal drugs should be carried out for a long time, continuously, and not in short courses. Evaluation of treatment should be based on clinical indicators and the results of objective instrumental methods (tests with physical activity, outpatient Holter ECG monitoring, etc.) due to possible painless myocardial ischemia. Treatment should be started with monotherapy, resorting to a combination of drugs only in the absence of desired effect. However, often the doctor does not prescribe the most effective dose of the drug, fearing the development of complications. Treatment of patients with angina should be differentiated and depend on the functional class (FC). Many doctors prefer not monotherapy, but a combination of several antianginal drugs, without using reserves of monotherapy, without selecting an effective dose of the drug, taking into account the individual sensitivity of the patient. Not all combinations of antianginal drugs give a total effect, sometimes the alternation of taking different drugs gives the best clinical effect. When switching from monotherapy to combination therapy, drugs with multidirectional hemodynamic and cytoprotective effects should be used.

Due to the availability of highly effective, but expensive drugs, it is necessary to take into account the economic factor, i.e. the possibility of acquiring or replacing an expensive drug with a similar inexpensive effective drug, especially in elderly patients.

Modern treatment of coronary artery disease, in addition to taking antianginal and anti-ischemic drugs, should include antithrombotic, lipid-lowering and metabolic agents. Due to the rapid development and implementation of angioplasty and stenting of the coronary arteries, the emergence of low-traumatic surgical interventions (minimal invasive direct coronary artery bypass grafting), patients refractory to medical treatment should be promptly referred to myocardial revascularization.

Drug treatment of chronic coronary artery disease

The main goals of treatment are: improving the patient's quality of life by reducing the frequency of angina attacks, preventing acute myocardial infarction, and improving survival. Successful antianginal treatment is considered in the case of complete or almost complete elimination of angina attacks and the return of the patient to normal activity (angina pectoris is not more than functional class I, when pain attacks occur only with significant stress) and with minimal side effects of therapy.

In the treatment of chronic coronary artery disease, 3 main groups of drugs are used: β-blockers, calcium antagonists, organic nitrates. These drugs significantly reduce the number of angina attacks, reduce the need for nitroglycerin, increase exercise tolerance and improve the quality of life of patients.

β-blockers. They are the main ones in the treatment of angina pectoris, however, until now, practitioners are reluctant to prescribe new effective β-blockers in sufficient doses. In addition, with a greater choice of modern drugs, some doctors use outdated, insufficiently effective drugs.

In our country, the situation with treatment with β-blockers is unsatisfactory. When prescribing various drugs in Russia, one of the first places is occupied by propranolol, an effective drug, but outdated and superseded in many countries by other modern β-blockers. Choose the right one effective drug a frank conversation with the patient helps, an explanation of the cause of the disease and its complications, the need for additional non-invasive research methods to assess the effect of treatment.

Such doses of β-blockers are considered equivalent, which contribute to the same decrease in the increase in heart rate during exercise (propranolol 100 mg, atenolol 100 mg, metoprolol 100 mg, oxprenolol 100 mg, acebutalol 200 mg, bisoprolol (Bisogamma 10 mg).

According to the results of the ATP-survey study (Angina Treatment Patterns), in Russia, when choosing antianginal drugs with a hemodynamic mechanism of action in monotherapy mode, preference is given to nitrates (11.9%), then to β-blockers (7.8%) and calcium antagonists ( 2.7%). However, with combined treatment, β-blockers are prescribed much more often - in 75% of cases.

Indications for the use of β-blockers are the presence of angina pectoris, angina pectoris with concomitant arterial hypertension, concomitant heart failure, silent myocardial ischemia, myocardial ischemia with concomitant arrhythmias. In the absence of direct contraindications, β-blockers are prescribed to all patients with coronary artery disease, especially after myocardial infarction. The main goal of therapy is to improve the long-term prognosis of a patient with coronary artery disease.

Among β-blockers propranolol (80-320 mg/day), atenolol (25-100 mg/day), metoprolol (50-200 mg/day), carvedilol (25-50 mg/day), bisoprolol (Bisogamma) are widely used (5-20 mg/day), nebivolol (5 mg/day). Drugs with cardioselectivity (atenolol, metoprolol, bisoprolol, betaxolol) have a predominantly blocking effect on β-1 adrenergic receptors. With long-term therapy, better tolerability of β1-selective blockers is of no small importance.

The use of β-blockers, especially bisoprolol (Bisogamma), not only reduces the severity of symptoms, but also improves the prognosis. The results of recent studies of bisoprolol have shown that in patients with angina pectoris, the number and duration of transient episodes of ischemia can be significantly reduced; treatment is accompanied by a decrease in such indicators as mortality and morbidity, as well as an improvement in the general condition of patients. The drug also reduces cardiovascular mortality and the risk of fatal myocardial infarction in high-risk patients undergoing cardiac surgery. Bisogamma helps to increase tolerance to physical activity in more than the use of atenolol and metoprolol, causes a significant increase in physical activity and a dose-dependent effect on exercise tolerance. It has been shown that bisoprolol improves the quality of life and reduces anxiety and fatigue to a much greater extent than atenolol and metoprolol. International studies show that bisoprolol improves the quality of life to a greater extent.

β-blockers should be given preference: in patients with coronary heart disease in the presence of a clear relationship between physical activity and the development of an angina attack, with concomitant arterial hypertension; the presence of arrhythmias (supraventricular or ventricular arrhythmias), with a previous myocardial infarction, a pronounced state of anxiety. Most of the adverse effects of β-blockers are associated with the blockade of β2 receptors. The need to control the prescription of β-blockers and the side effects that occur (bradycardia, hypotension, bronchospasm, increased signs of heart failure, heart block, sick sinus syndrome, fatigue, insomnia) lead to the fact that the doctor does not always use this valuable class of drugs .

The main medical errors in the appointment of β-blockers are: the use of small doses of drugs, their appointment less often than necessary, and the abolition of drugs when heart rate at rest is less than 60 beats per minute. It should also be borne in mind the possibility of developing a withdrawal syndrome, and therefore β-blockers must be canceled gradually.

calcium antagonists along with pronounced antianginal (anti-ischemic) properties, they can have an additional anti-atherogenic effect (stabilization of the plasma membrane, which prevents the penetration of free cholesterol into the vessel wall), which allows them to be prescribed more often to patients with stable angina pectoris with damage to arteries of various localization.

Currently, calcium antagonists are considered second-line drugs in patients with exertional angina, following β-blockers. As monotherapy, they can achieve the same pronounced antianginal effect as β-blockers. However, the undoubted advantage of β-blockers over calcium antagonists is their ability to reduce mortality in patients with myocardial infarction. Studies on the use of calcium antagonists after myocardial infarction have shown that the greatest effect is achieved in individuals without severe left ventricular dysfunction, suffering from arterial hypertension, who have had myocardial infarction without a Q wave.

The undoubted advantages of calcium antagonists is a wide range of their pharmacological effects aimed at eliminating the manifestations of coronary insufficiency - antianginal, hypotensive, antiarrhythmic effects. Therapy with these drugs also favorably affects the course of atherosclerosis. Verapamil and diltiazem should be used in cases where β-blockers are contraindicated for the patient (obstructive bronchitis, bronchial asthma) or cause side effects (severe sinus bradycardia, sick sinus syndrome, general weakness, slowing atrioventricular conduction, impotence, etc.). According to controlled studies in patients with coronary artery disease with stable angina, the recommended equivalent dose of calcium antagonists is: for nifedipine 30-60 mg / day, verapamil 240-480 mg / day, diltiazem 90-120 mg / day, amlodipine 5-10 mg / day. .

organic nitrates(preparations of nitroglycerin, isosorbide dinitrate and isosorbide-5-mononitrate) are used to prevent angina attacks. These drugs provide long-term hemodynamic unloading of the heart, improve blood supply to ischemic areas and increase physical performance. They are tried to be prescribed before physical exertion that causes angina pectoris. Of the nitrates, the most studied drugs with proven efficacy are kardiket (20, 40, 60 and 120 mg/day), nitrosorbide (40-80 mg/day), olicard retard (40 mg/day), monomak (20-80 mg/day ), monomac depot (50 and 100 mg/day), efox long (50 mg/day), monocinque retard (50 mg/day). Patients with stable angina pectoris I-II FC may intermittent administration of nitrates, i.e. before situations that can cause an attack of angina pectoris. Patients with a more severe course of angina pectoris III-IV FC nitrates should be prescribed regularly; in such patients, it is necessary to strive to maintain the effect during the day. With angina pectoris IV FC (when angina attacks can occur at night), nitrates should be prescribed in such a way as to ensure an antianginal effect throughout the day.

Nitrate-like drugs include molsidomine (Corvaton, Sidnopharm) - a drug different from nitrates in chemical structure, but no different from them in terms of the mechanism of action. The drug reduces vascular wall tension, improves collateral circulation in the myocardium and has antiaggregatory properties. Comparable doses of isosorbide dinitrate and corvatone are 10 mg and 2 mg, respectively. The effect of Korvaton appears after 15-20 minutes, the duration of action is from 1 to 6 hours (average 4 hours). Corvaton-retard 8 mg is taken 1-2 times a day, since the effect of the drug lasts more than 12 hours.

The weak side of nitrates is the development of tolerance to them, especially with prolonged use, and side effects that make it difficult to use them (headache, palpitations, dizziness) caused by reflex sinus tachycardia. Transdermal forms of nitrates in the form of ointments, patches and disks, due to the difficulty of their dosing and the development of tolerance to them, have not found wide application. It is also unknown whether nitrates improve the prognosis of a patient with stable angina pectoris with long-term use, which makes it doubtful whether they should be prescribed in the absence of angina pectoris (myocardial ischemia).

It is not uncommon in medical practice that there is such an extreme as overdiagnosis of coronary artery disease and the use of antianginal drugs (most often nitrates) on a “just in case” basis. Thus, according to the EPOHA epidemiological study, the frequency of use of various nitrates in a representative sample of Russian patients with cardiovascular pathology reached 55%. At the same time, in European studies in a similar sample of patients, the frequency of nitrate use is only 30-32%. It is obvious that such tactics of managing patients with coronary artery disease can bring nothing but harm.

There are features of the appointment of antianginal drugs in elderly patients. When prescribing drugs with a hemodynamic mechanism of action in this group of patients, the following rules should be observed: start treatment with lower doses, carefully monitor undesirable effects, and always consider the possibility of replacing the drug if it is poorly tolerated and insufficiently effective.

Myocardial cytoprotectors

Anti-ischemic and antianginal efficacy of trimetazidine has now been proven. Indications for the appointment of trimetazidine: IHD, prevention of angina attacks during long-term treatment. Contraindication for trimetazidine is individual intolerance; due to the lack of clinical data, the drug should not be taken during pregnancy.

The mechanism of action of trimetazidine is associated with the suppression of beta-oxidation of fatty acids and increased pyruvate oxidation under conditions of ischemia, which leads to the preservation in cardiomyocytes required level adenosine triphosphate, reduction of intracellular acidosis and excess accumulation of calcium ions. Preductal is prescribed 3 times a day, 20 mg. New dosage form trimetazidine - trimetazidine modified release (MR), due to the improved pharmacokinetic profile, provides a constant anti-anginal and anti-ischemic efficacy for 24 hours. Preductal MB has a more convenient dosing regimen - it is prescribed at a dose of 35 mg 2 times a day. Trimetazidine (preductal MB, preductal) may be given at any stage of therapy for stable angina to enhance antianginal efficacy. There are a number of clinical situations in which trimetazidine, apparently, can be the drug of choice: in patients with angina pectoris of advanced age, with circulatory failure of ischemic origin, sick sinus syndrome, with intolerance to hemodynamic antianginal agents, as well as with restrictions or contraindications to their purpose.

ACE inhibitors

ACE inhibitors (captopril, enalapril, quinapril, lisinopril, perindopril, fosinopril, etc.) affect the main pathological processes - vasoconstriction, structural changes in the vascular wall, left ventricular remodeling, thrombus formation, underlying coronary heart disease. The protective effect of ACE inhibitors in relation to the development of atherosclerosis, apparently, is due to a complex mechanism of their action: a decrease in the level of angiotensin II and an increase in the production of nitric oxide, as well as an improvement in the function of the vascular endothelium. One of the mechanisms of the anti-ischemic action of ACE inhibitors is arteriovenous peripheral vasodilation, which eliminates hemodynamic overload of the heart (both filling and resistance) and a decrease in pressure in the ventricles. In addition, the drugs have a direct positive effect on coronary blood flow, reducing vasopressor sympathetic-adrenal effects, potentiating the effects of nitro drugs (often prescribed for patients with angina pectoris) and eliminating tolerance to them, and also having a direct vasodilating effect on the coronary vessels.

Some ACE inhibitor drugs (monopril) have a beneficial effect on the daily blood pressure profile, which ensures a stable level of afterload hemodynamics on the left ventricle of the heart throughout the day. Perhaps it is this feature of the antihypertensive effect that determines the ability of monopril to selectively eliminate episodes of nocturnal (clinostatic) myocardial ischemia.

Lipid-lowering drugs

The most effective drugs are statins. (lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin). The indication for taking statins in patients with coronary artery disease is the presence of hyperlipidemia with insufficient effect of diet therapy.

In a recent large-scale epidemiological and pharmacoepidemiological clinical study of ATP (Angina Treatment Pattern), it was shown that in most cases in Russian Federation there is no adequate control of lipid metabolism in individuals with risk factors for coronary artery disease and in patients with stable angina pectoris, and adequate therapy of hyperlipidemia with modern medicines. The therapeutic effect of statins may be associated with the stabilization of atherosclerotic plaques, a decrease in their tendency to rupture, an improvement in endothelial function, a decrease in the tendency of coronary arteries to spastic reactions, and suppression of inflammatory reactions. Statins have a positive effect on a number of indicators that determine the tendency to form blood clots - blood viscosity, platelet and erythrocyte aggregation, and fibrinogen concentration.

When prescribing original statin drugs used for a long time (5 years or more), it is necessary to take into account their high cost, so they are not affordable for many patients. The list of benefit categories is very limited and does not include all patients who need to take statins. The cost of generic statins is much lower; these drugs are registered in Russia and approved for clinical use. They are prescribed in doses of 20-40 mg per day.

In the case of a complicated course of coronary artery disease, accompanied by a rhythm disorder, the entire spectrum of antiarrhythmic drugs is used. Here it should be noted Magnerot, which is magnesium orotate and is used in the composition complex therapy and for the prevention of spastic conditions, atherosclerosis and hyperlipidemia.

Surgical treatment of coronary artery disease

The more severe the atherosclerosis of the coronary arteries, the less effect can be expected from the effects of antianginal drugs of hemodynamic action. The lack of effect or insufficient effectiveness of drug therapy, the progressive nature of angina are indications for coronary angiography. Left ventricular dysfunction in an asymptomatic patient does not seem to justify coronary angiography. However, the presence of other indicators of non-invasive testing that are associated with a high risk and reflect myocardial ischemia, such as a high risk on the treadmill test (Duke index), low exercise tolerance, severe ST segment depression, the presence of a large perfusion defect on a stress test, or Identification during stress echocardiography of violations of the normal movement of the LV wall at a low heart rate is likely to serve as direct indications for coronary angiography.

If drug therapy is ineffective, surgical methods of treatment (myocardial revascularization operations) are used, which include: percutaneous transluminal coronary angioplasty, implantation of coronary stents, coronary artery bypass grafting (CABG). In patients with coronary artery disease, it is important to determine the individual risk based on clinical and instrumental indicators, which depends on the appropriate clinical stage of the disease and the treatment being carried out. Thus, the maximum efficiency of coronary artery bypass grafting was noted in patients with the highest preoperative risk of developing cardiovascular complications (with severe angina pectoris and ischemia, extensive lesions of the coronary arteries, impaired left ventricular function). If the risk of CAD complications is low (single artery disease, no or mild ischemia, normal left ventricular function), surgical revascularization is usually not indicated until medical therapy or coronary angioplasty has been proven to be ineffective. When considering the use of coronary angioplasty or coronary artery bypass grafting for the treatment of patients with lesions of multiple coronary arteries, the choice of method depends on the anatomical features of the coronary bed, left ventricular function, the need to achieve complete myocardial revascularization and patient preferences.

Less invasiveness, the possibility of repeated (multiple) use in restenosis or progression of coronary atherosclerosis, lower cost of manipulation, which does not require anesthesia and a heart-lung machine, are the main advantages of endovascular angioplasty over coronary artery bypass grafting. Stenting is also performed for chronic arterial occlusions, recurrence of angina pectoris after CABG. However, the occurrence of acute occlusions (up to 5%) and restenoses (up to 30%) reduce the effectiveness of angioplasty, therefore, at present, most patients after angioplasty undergo intravascular stenting with a drug-eluting stent, which reduces the risk of restenoses.

Thus, in stable angina pectoris, revascularization is indicated only in case of failure of adequate drug therapy or in case of extremely unfavorable prognostic damage to the coronary arteries. Unfortunately, myocardial revascularization procedures in our country remain inaccessible for the majority of IHD patients. Thus, according to the ATP study, among patients with chronic coronary artery disease, coronary bypass surgery is performed only in 3-4% of patients, and coronary angioplasty - in 2% of patients.

CABG, balloon dilatation and stenting of the coronary arteries occupy an important place in the treatment of coronary artery disease, but they cannot replace other methods of treatment. Antianginal and anti-ischemic agents often become a necessary addition to surgical treatment, both before and after it.

Due to the small number of coronary bypass operations performed in Russia, they do not play such a significant role in improving the situation as a whole as in other countries. A significant role in the survival of patients with coronary artery disease belongs to proven favorable interventions for the prognosis (β-blockers, ACE inhibitors, statins, antiplatelet agents, ASA). After coronary angioplasty and stenting, secondary prevention should be continued, taking into account the presence of risk factors in the patient and indications and contraindications for prescribing drugs. These measures include treatment of arterial hypertension and diabetes mellitus, intensive lipid-lowering therapy, smoking cessation, weight loss, and regular exercise.

Sometimes doctors are reluctant to use "aggressive treatment" in old and elderly patients, although conventional antianginal drugs in this category of patients are as effective as in young and middle-aged people. In terms of disease prognosis, older people benefit from medical treatment, angioplasty, and CABG as much as younger patients.

Secondary prevention

The goal of secondary prevention is to stop the progression of the disease, prevent clinical complications and, thereby, prevent premature death of the patient.

ASA and other antiplatelet agents

ASA (acetylsalicylic acid) is by far the only antithrombotic drug whose clinical efficacy in secondary prevention has been confirmed by numerous controlled trials and meta-analyses. The mechanism of action of ASA is the irreversible inhibition of platelet cyclooxygenase activity, followed by a decrease in the synthesis of thromboxane A2 and prostacyclin. ASA blocks the platelet release reaction induced by ATP and norepinephrine. There is varying individual susceptibility to ASA, but clinical diagnosis and its evaluation have not been fully developed.

According to current international recommendations, all patients with coronary artery disease, in the absence of contraindications, should take ASA at a dose of 75-325 mg per day, regardless of the presence of cardiac symptoms. It has been proven that the appointment of ASA in patients with stable angina significantly reduces the risk of developing cardiovascular complications by 33-50%. Suppression of platelet function is apparently accompanied by inhibition of thrombosis, which is manifested by a decrease in the frequency of thrombotic complications of atherosclerosis. Long-term regular treatment with ASA in doses of 75-325 mg per day is accompanied by a 20-40% reduction in the risk of developing recurrent myocardial infarction. ASA, when administered early after coronary bypass surgery, reduces the incidence of bypass thrombosis by 50%. Most patients with coronary artery disease ASA should be taken throughout life. For secondary prevention of coronary artery disease, ASA is prescribed in small doses (75-150 mg/day), with an increased risk of thrombosis, the dose of ASA is increased to 325 mg/day. Currently, the point of view dominates, according to which ASA is indicated for all patients with coronary artery disease. ASA is contraindicated in peptic ulcer, hemorrhagic diathesis, individual intolerance, renal and hepatic insufficiency, in some cases with bronchial asthma. However, the appointment of ASA to a patient without a confirmed diagnosis of coronary artery disease cannot be justified, including due to an increased risk of gastrointestinal bleeding.

Ticlopidin (ticlid) affects platelet aggregation by inhibiting the binding of adenosine diphosphate (ADP) to its receptor on the platelet, without affecting cyclooxygenase, like ASA, but by blocking thromboxane synthetase. The bleeding time when taking ticlopidine is approximately twice as long as the initial value. The suppression of platelet aggregation is recorded within two days from the start of the use of ticlopidine at a dose of 250 mg twice a day, and the maximum effect is achieved on the 5th day of treatment. The disadvantages of ticlopidine include erosive and ulcerative lesions of the gastrointestinal tract, skin rash, neutropenia, thrombocytopenia and thrombocytopenic purpura. Currently, ticlopidine is being replaced by clopidogrel, which has fewer side effects and requires less stringent monitoring of blood counts during treatment.

Indirect anticoagulants

The appointment of warfarin (5 mg / day) both as monotherapy and in combination with ASA is justified in patients with coronary artery disease with a high risk of vascular complications - in the presence of intracardiac thrombosis, episodes of thromboembolic complications in history, atrial fibrillation, deep vein thrombosis, when it can be assumed that that the appointment of ASA alone as a means of secondary prevention will not be enough. At the same time, careful monitoring of the INR level is necessary, which requires repeated laboratory studies. In addition to warfarin, other indirect anticoagulants are also used - neodicoumarin, pelentan, syncumar, phenylin.

Tactics of outpatient management of patients with stable coronary artery disease

During the first year of the disease, if the patient's condition is stable and the drug treatment is well tolerated, the condition of patients should be assessed every 4-6 months. If in the future the condition remains stable and the patient is able to adequately assess it, then it is quite sufficient to conduct an outpatient examination once a year. Otherwise, outpatient visits should be more frequent. To assess the condition of the patient (especially the elderly) is often helped by questioning his relatives and friends.

If the course of coronary artery disease worsens or side effects of the treatment appear, the patient or his relatives should actively contact the doctor with an extraordinary visit.

Conclusion

In recent years, there has been significant progress in the field of medical and surgical treatment of patients with coronary artery disease. However, it has not yet been possible to use these achievements effectively and to the full extent. This is largely due to economic and organizational problems. For example, until now, in each group of antiaginal drugs, old drugs are predominantly used, and not modern, most effective and safe ones that improve the prognosis of patients with coronary artery disease.

The problem of drug treatment of patients with coronary artery disease is the lack of adherence of patients to the chosen therapy and their insufficient willingness to consistently change their lifestyle. With drug treatment, proper regular contact between the doctor and the patient is necessary, informing the patient about the nature of the disease and the benefits of prescribed drugs to improve the prognosis. Trying to influence the prognosis of the life of patients with the help of drug therapy, the doctor must be sure that the drugs prescribed by him are actually taken by the patient, and at the appropriate doses and according to the recommended treatment regimen.

Prescribing antianginal drugs for practical work a cardiologist is often carried out empirically, by trial and error, dynamic observation and personal experience. One should strive for an individual selection of therapy, which consists in: substantiating the appointment of a specific drug or combination of antianginal drugs, choosing a rational treatment regimen, including the use of drugs other than antianginal and antiischemic drugs.

Currently, the ‘’natural’’ course of stable angina pectoris is affected by a complex of anti-ischemic, antithrombotic, hypotensive, lipid-lowering, cytoprotective and other types of treatment, as well as frequent procedures for myocardial revascularization, which gives the disease a new development associated with the results of interventions.

The results of repeated examinations of patients, the possibility of their timely hospitalization, dispensary observation, secondary prevention play an important role in the effectiveness of treatment and the prognosis of survival in patients with coronary artery disease.

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