Cardiologist: who is he, what does he do, what does he treat?

Cardiology

(from ancient Greek καρδία - heart and λόγος - study) - an extensive branch of medicine dealing with the study of the human cardiovascular system: the structure and development of the heart and blood vessels, their functions, as well as diseases, including the study of the causes of their occurrence, mechanisms of development , clinical manifestations, diagnostic issues, as well as the development of effective methods for their treatment and prevention. In addition, in the field of cardiology there are problems of medical rehabilitation of persons with lesions of the cardiovascular system.

History of cardiology

Cardiology studies such pathological conditions as coronary heart disease (CHD), hypertension, congenital heart defects, acquired heart defects, cerebrovascular diseases and others. Today, the share of cardiac pathology in the structure of mortality of the population of developed countries is 40-60%, with a continuing increase in incidence and damage to increasingly younger people, which makes cardiovascular diseases the most important medical and social health problem.

The history of cardiology, like the history of medicine in general, goes back thousands of years. Since ancient times, the work of the heart and blood vessels has been a mystery, the unraveling of which occurred gradually over many centuries.

An understanding of the importance of the work of the heart for the body can be found in the ancient Egyptian Ebers papyrus (XVII century BC):

“The beginning of the secrets of a doctor is knowledge of the course of the heart, from which vessels go to all members, for every doctor, every priest of the goddess Sokhmet, every spellcaster, touching the head, back of the head, arms, palms, legs, touches the heart everywhere: from it the vessels are directed to each member..."

12 centuries later (5th century BC), a resident of the Greek island of Kos, Hippocrates, first describes the structure of the heart as a muscular organ. Even then, he formed an idea of ​​the ventricles of the heart and large vessels.

The Roman physician Galen (2nd century AD) created a new, revolutionary teaching for his time, which for a long time changed people’s understanding of the work of the heart and blood vessels. There were many inaccuracies in Galen's works, and there were also gross errors. This is, for example, his description of the path of blood in the body.

Galen considered the center of the circulatory system not the heart, but the liver: the blood formed in the liver spreads throughout the body, nourishes it and is completely absorbed by it, without returning back; the liver produces the next batch of blood for absorption by the body. This scheme was generally accepted until the 17th century, when Harvey proved it wrong. Thus, without knowing blood circulation, Galen imagined a kind of blood supply system to the body. Considering the purpose of the left heart to attract pneuma from the lungs along with air, he considered stretching - diastole, as an active movement of the heart, and systole - as a passive contraction of the heart, that is, he understood these processes completely wrong. It is not surprising that Galen could not explain the processes occurring in the body and attributed them to immaterial forces that were originally inherent in man.

A serious breakthrough in the development of ideas about the work of the cardiovascular system occurred during the Renaissance. The ability to dissect corpses allowed Leonardo da Vinci to create many anatomical illustrations, which, among other things, quite accurately depicted the structure of the heart valves. Many of Galen's errors were discovered and described by Andreas Vesalius, who created the basic prerequisites for the subsequent discovery of pulmonary circulation. Vesalius carefully describes the arteries and veins. The laws of branching of arteries and the paths of circuitous blood flow do not remain hidden for him. Even the structural features of the vascular wall attract his attention. The fact remains that veins for Vesalius are vessels through which blood from the liver goes to the periphery. Next to them, the arteries carry blood, saturated with the vital spirit, from the heart to the periphery. Vesalius does not know how the thinnest vascular tubes end. For him, the heart is an ordinary internal organ, and not the center of the vascular system. Vesalius places the importance of veins higher than arteries. But the description of the topography of the veins still suffers from inaccuracies. For example, the formation of the portal vein is not clearly shown by Vesalius. It allows the connection of the arteries of the brain with the sinuses of the dura mater. The variability of the veins is obvious to him. The works of Vesalius were a necessary step. Only on the basis of complete knowledge of the distribution of blood vessels could a new theory be built.

A huge leap in the development of physiological knowledge was the activity of William Harvey (1578-1657), an English physician who studied blood circulation, at the University of Padua. Harvey was the first to experimentally prove the existence of blood circulation. Harvey conducted a series of experiments, first on himself and then on a dog, which proved that blood in the veins moves in one direction. Harvey created objectively real ideas about the laws of blood circulation. He was the first to mathematically calculate that the entire volume of blood passes through the heart in 1.5-2 minutes, and within 30 minutes the main “pump of life” pumps an amount of blood equal to the weight of the body.

This is what William Harvey wrote in his classic work Anatomical Studies on the Movement of the Heart and Blood in Animals, published in 1628: “The movement of blood through the lungs and heart, as well as throughout the rest of the body, occurs by the force of the pulsation of the ventricles, passing imperceptibly (for observation) into the veins and pores of the soft parts, the blood then flows independently through the veins from the periphery to the center, from smaller veins to larger ones, and from there, finally, through the vena cava it passes into the heart tube. Therefore, it must be concluded that the blood in the animal’s body is distributed throughout the body in a kind of circular manner.” Galen's ideas were completely refuted.

In the circulatory system. presented by Harvey, was missing an important link - capillaries, since Harvey did not use a microscope. Marcello Malpighi (1628-1694) was the first of the researchers of the circulatory system to use this device, which allowed him to gain a complete understanding of the circular movement of blood. This is how the last mystery of the circulatory system was solved. Simultaneously with this discovery, Malpighi finally refuted Galen's ideas about blood circulation.

Domestic scientists also contributed to the study of capillaries. Alexander Shumlyansky (1748-1795) proved that arterial capillaries directly pass into certain “intermediate spaces,” as Malpighi believed, and that the vessels are closed along their entire length.

The structure of the lymphatic system and its connection with blood vessels was described by the Italian surgeon Gaspar Azeli (1581-1626).

Jean Nicolas Corvisart de Marais (1755-1821), the founder of clinical medicine in France, physician-in-chief of Napoleon I, carefully studied percussion sound as a new diagnostic tool. Corvisart was the first to use percussion using the palm of his hand. This method allowed him to recognize with great skill lung diseases, the presence of fluid in the pleural cavity and pericardial sac, as well as cardiac aneurysm, the study of which brought Corvisart great fame.

The founder of another method of physical examination - auscultation - can be considered Rene Theophilus Hyacinthe Laennec. Returning from the clinic through the Louvre park, he noticed a noisy group of children playing around the logs of the construction forest. Some children put their ears to it. to the end of the log, and others with great enthusiasm beat with sticks on the opposite end: the sound, intensifying, went inside the tree. This observation allowed Laennec to create the first stethoscope.

In 1846, the Czech physiologist Purkinje published research on specific muscle fibers that conduct excitation through the heart (Purkinje fibers), which laid the foundation for the study of its conduction system. V. Gis described the atrioventricular bundle in 1893, L. Aschoff in 1906, together with Tavara, described the atrioventricular (atrioventricular) node, A. Kis in 1907, together with Flex, described the sinoatrial node.

Thanks to all these discoveries, by the beginning of the 19th century. Cardiology has become an independent branch of medicine, which has its own methods of diagnosis, treatment and prevention of diseases of the cardiovascular system [1].

Anatomy of the coronary arteries

extra_toc

At the moment, there are many options for classification of coronary arteries adopted in different countries and centers of the world. But, in our opinion, there are certain terminological differences between them, which creates difficulties in the interpretation of coronary angiography data by specialists of different profiles.

We analyzed the literature on the anatomy and classification of the coronary arteries. Data from literary sources are compared with our own. A working classification of coronary arteries has been developed in accordance with the nomenclature accepted in the English-language literature.

Coronary arteries

From an anatomical point of view, the coronary artery system is divided into two parts - right and left.

From a surgical perspective, the coronary bed is divided into four parts: the left main coronary artery (trunk), the left anterior descending artery or anterior interventricular branch (LAD) and its branches, the left circumflex coronary artery (OC) and its branches, the right coronary artery (RCA). ) and its branches.

The large coronary arteries form an arterial ring and loop around the heart. The left circumflex and right coronary arteries participate in the formation of the arterial ring, passing along the atrioventricular groove.

The formation of the arterial loop of the heart involves the anterior descending artery from the left coronary artery system and the posterior descending artery from the right coronary artery system, or from the left coronary artery system - from the left circumflex artery with a left dominant type of blood supply. The arterial ring and loop are a functional device for the development of collateral circulation of the heart.

Right coronary artery

The right coronary artery arises from the right sinus of Valsalva and runs in the coronary (atrioventricular) groove. In 50% of cases, immediately at the place of origin, it gives off the first branch - the branch of the arterial cone (conus artery, conus branch, CB), which feeds the infundibulum of the right ventricle.

Its second branch is the sinoatrial node artery (SA node artery, SNA), which extends from the right coronary artery back at a right angle into the space between the aorta and the wall of the right atrium, and then along its wall to the sinoatrial node. As a branch of the right coronary artery, this artery is found in 59% of cases.

In 38% of cases, the artery of the sinoatrial node is a branch of the left circumflex artery. And in 3% of cases there is blood supply to the sinoatrial node from two arteries (both from the right and from the circumflex).

In the anterior part of the coronary sulcus, in the region of the acute edge of the heart, the right marginal branch (acute marginal artery, acute marginal branch, AMB), usually from one to three, departs from the right coronary artery, which in most cases reaches the apex of the heart.

Then the artery turns back, lies in the back of the coronary sulcus and reaches the “cross” of the heart (the intersection of the posterior interventricular and atrioventricular sulcus of the heart).

With the so-called right type of blood supply to the heart, observed in 90% of people, the right coronary artery gives off the posterior descending artery (PDA), which runs along the posterior interventricular groove at various distances, giving off branches to the septum (anastomosing with similar branches from the anterior descending artery, the latter usually longer than the first), the right ventricle and branches to the left ventricle. After the origin of the posterior descending artery (PDA), the RCA continues beyond the cross of the heart as the right posterior atrioventricular branch along the distal part of the left atrioventricular groove, ending in one or more posterolateral branches supplying the diaphragmatic surface of the left ventricle . On the posterior surface of the heart, immediately below the bifurcation, at the junction of the right coronary artery with the posterior interventricular groove, an arterial branch originates from it, which, piercing the interventricular septum, goes to the atrioventricular node - the atrioventricular node artery (AVN).

The branches of the right coronary artery vascularize: the right atrium, part of the anterior wall, the entire posterior wall of the right ventricle, a small portion of the posterior wall of the left ventricle, the interatrial septum, the posterior third of the interventricular septum, the papillary muscles of the right ventricle and the posterior papillary muscle of the left ventricle.

Left coronary artery

The left coronary artery starts from the left posterior surface of the aortic bulb and exits on the left side of the coronary sulcus.

Its main trunk (left main coronary artery, LMCA) is usually short (0-10 mm, diameter varies from 3 to 6 mm) and is divided into the anterior interventricular (left anterior descending artery, LAD) and circumflex artery (LCx) branches .

In 30-37% of cases, the third branch arises here - the intermediate artery (ramus intermedius, RI), which crosses obliquely the wall of the left ventricle. The LAD and OB form an angle between themselves that varies from 30 to 180°.

Anterior interventricular branch

The anterior interventricular branch is located in the anterior interventricular groove and goes to the apex, giving off the anterior ventricular branches (diagonal artery, D) and anterior septal branches along the way. In 90% of cases, one to three diagonal branches are determined.

The septal branches depart from the anterior interventricular artery at an angle of approximately 90 degrees and pierce the interventricular septum, feeding it.

The anterior interventricular branch sometimes enters the thickness of the myocardium and again lies in the groove and along it often reaches the apex of the heart, where in approximately 78% of people it turns posteriorly onto the diaphragmatic surface of the heart and at a short distance (10-15 mm) rises upward along the posterior interventricular groove.

In such cases, it forms the posterior ascending branch. Here it often anastomoses with the terminal branches of the posterior interventricular artery, a branch of the right coronary artery.

Circumflex artery

The circumflex branch of the left coronary artery is located in the left part of the coronary sulcus and in 38% of cases gives the first branch to the artery of the sinoatrial node, and then the obtuse marginal artery (obtuse marginal branch, OMB), usually from one to three. These fundamentally important arteries supply the free wall of the left ventricle.

In the case when there is a right type of blood supply, the circumflex branch gradually becomes thinner, giving off branches to the left ventricle. In the relatively rare left type (10% of cases), it reaches the level of the posterior interventricular groove and forms the posterior interventricular branch. In an even rarer case, the so-called mixed type, there are two posterior ventricular branches of the right coronary and circumflex arteries.

The left circumflex artery forms important atrial branches, which include the left atrial circumflex artery (LAC) and the large anastomosing artery of the appendage.

The branches of the left coronary artery vascularize the left atrium, the entire anterior and most of the posterior wall of the left ventricle, part of the anterior wall of the right ventricle, the anterior 2/3 of the interventricular septum and the anterior papillary muscle of the left ventricle.

Types of blood supply to the heart

The type of blood supply to the heart is understood as the predominant distribution of the right and left coronary arteries on the posterior surface of the heart. The anatomical criterion for assessing the predominant type of distribution of the coronary arteries is the avascular zone on the posterior surface of the heart, formed by the intersection of the coronary and interventricular grooves - crux.

Depending on which artery - right or left - reaches this zone, the predominant right or left type of blood supply to the heart is distinguished. The artery reaching this zone always gives off the posterior interventricular branch, which runs along the posterior interventricular groove towards the apex of the heart and supplies the posterior part of the interventricular septum.

Another anatomical sign is described to determine the predominant type of blood supply. It has been noted that the branch to the atrioventricular node always arises from the predominant artery, i.e. from the artery that is most important in supplying blood to the posterior surface of the heart.

Thus, with a predominant right type of blood supply to the heart, the right coronary artery supplies the right atrium, right ventricle, posterior part of the interventricular septum and posterior surface of the left ventricle. The right coronary artery is represented by a large trunk, and the left circumflex artery is poorly expressed.

With the predominant left type of blood supply to the heart, the right coronary artery is narrow and ends in short branches on the diaphragmatic surface of the right ventricle, and the posterior surface of the left ventricle, the posterior part of the interventricular septum, the atrioventricular node and most of the posterior surface of the ventricle receive blood from the well-defined large left circumflex artery. In addition, a balanced type of blood supply is also distinguished, in which the right and left coronary arteries make approximately equal contributions to the blood supply to the posterior surface of the heart. The concept of “predominant type of blood supply to the heart,” although conditional, is based on the anatomical structure and distribution of the coronary arteries in the heart. Since the mass of the left ventricle is significantly greater than the right, and the left coronary artery always supplies most of the left ventricle, 2/3 of the interventricular septum and the wall of the right ventricle, it is clear that the left coronary artery is the predominant one in all normal hearts. Thus, with any type of coronary blood supply, the left coronary artery is predominant in a physiological sense.

Nevertheless, the concept of “predominant type of blood supply to the heart” is valid, is used to assess anatomical findings during coronary angiography and is of great practical importance in determining indications for myocardial revascularization.

For topical indication of lesion sites, it is proposed to divide the coronary bed into segments

The dotted lines in this diagram highlight the segments of the coronary arteries.

Thus, in the left coronary artery in the anterior interventricular branch it is divided into three segments:

1. proximal – from the place of origin of the LAD from the trunk to the first septal perforator or 1DV.2. average – from 1DV to 2DV.3. distal – after departure of the 2DV.

It is also customary to distinguish three segments in the circumflex artery:

1. proximal – from the mouth of the OB to 1 VTK.2. average – from 1 VTK to 3 VTK.3. distal – after separation of 3 VTCs.

The right coronary artery is divided into the following main segments:

1. proximal – from the mouth to 1 VOK2. medium – from 1 VOC to the acute edge of the heart

3. distal – before the bifurcation of the RCA into the posterior descending and posterolateral arteries.

Coronary angiography (coronary angiography) is x-ray visualization of the coronary vessels after the injection of a radiopaque contrast agent. The X-ray image is simultaneously recorded on 35 mm film or digital media for subsequent analysis.

At the moment, coronary angiography is the “gold standard” for determining the presence or absence of stenosis in coronary disease. The purpose of coronary angiography is to determine the coronary anatomy and the degree of narrowing of the lumen of the coronary arteries.

Information obtained during the procedure includes determination of the location, extent, diameter and contours of the coronary arteries, the presence and degree of coronary obstruction, characterization of the nature of the obstruction (including the presence of atherosclerotic plaque, thrombus, dissection, spasm or myocardial bridge).

The data obtained determine the further tactics of treating the patient: coronary bypass surgery, intervention, drug therapy. To conduct high-quality angiography, selective catheterization of the right and left coronary arteries is necessary, for which a large number of diagnostic catheters of various modifications have been created.

The examination is carried out under local anesthesia and NLA through arterial access. The following arterial approaches are generally accepted: femoral arteries, brachial arteries, radial arteries. Transradial access has recently gained a strong position and has become widely used due to its low morbidity and convenience.

After puncture of the artery, diagnostic catheters are inserted through the introducer, followed by selective catheterization of the coronary vessels. The contrast agent is administered in doses using an automatic injector. Filming is performed in standard projections, the catheters and intravener are removed, and a compression bandage is applied.

Diseases in cardiology

Cardiology deals with the study, diagnosis, treatment and prevention of the following diseases:

• heart defects (congenital and acquired);
• IHD (coronary heart disease);
• angina pectoris;
• carditis (endocarditis, pericarditis, etc.);
• heart failure of various etiologies;
• arrhythmias: bradycardia, tachycardia, incomplete heart block;
• hypertonic disease;
• thrombosis and thrombophlebitis;
• heart attacks and pre-infarction conditions;
• aneurysms (that is, abnormal bulgings and thinning of the walls) of the aorta or other arteries.

Over the years, the prevention of cardiovascular diseases, its strategies and patterns in different clinical situations has become increasingly important. The introduction of effective treatment and prevention measures in cardiology in Western Europe, the USA, Australia, and Japan has made it possible to reduce cardiovascular mortality in these countries by 50% over the past 20 years.

Diagnostic methods during observation by a cardiologist

An examination by a cardiologist begins with a questioning of the patient. The doctor will ask about the complaints in search of the above, clarify how long ago they appeared, under what conditions and how they changed, whether the patient addressed them to a therapist or another doctor, and, if so, what treatment he is receiving. Next, the cardiologist will ask:

• whether the patient has bad habits;
• Do your relatives have cardiovascular diseases?
• does he have concomitant diseases, especially endocrine and renal diseases;
• what illnesses or injuries he managed to suffer, in particular sore throat, erysipelas;
• Does he keep a blood pressure diary?

After this, the specialist will proceed to the examination. Measure height and weight to calculate the possible degree of obesity. Feel the pulse in the arms, neck, legs, evaluate the saphenous veins and the presence of edema. Listen to breathing and heartbeat through a phonendoscope, assessing the rhythm, its correctness, frequency, and the presence of noise on the valves. Check for murmurs over the carotid arteries. Finally, he will measure blood pressure in both arms and, if necessary, in the legs. The doctor can check the pulse and blood pressure again after a functional test (squats).

The next stage is laboratory and instrumental examination. Usually, you come to a consultation with a cardiologist with fresh tests ready. Or he orders them to be re-examined. The recommended minimum tests are:

• general blood tests (with platelets) and urine;
• biochemical blood test with indicators of glucose, creatinine, urea;
• lipid profile;
• coagulogram.

The most informative methods for making a diagnosis are instrumental research methods:

1. Electrocardiography (ECG).
2. Echocardiography (ultrasound of the heart) - to identify septal defects, valve defects, infarction areas, post-infarction scars or cardiac aneurysms, signs of cardiomyopathy, fluid accumulation in the pericardial cavity.
3. ECG, EchoCG with stress (physical or pharmacological) test - to identify signs of angina pectoris or arrhythmias that provoke stress.
4. 24-hour blood pressure monitoring (ABPM) – to confirm the diagnosis of hypertension and exclude situational jumps in blood pressure.
5. Daily ECG monitoring (SM-ECG) - to identify signs of angina or rhythm disturbances and their correlation with symptoms and provoking factors.
6. Ultrasound examination of the aorta and large arteries (cervical, renal, arteries of the arms, legs) with Dopplerography - to identify stenosing atherosclerosis, thrombosis, aneurysm or pathology of arterial development.
7. Coronary angiography is a series of x-rays of the arteries of the heart filled with a contrast agent; the contrast enters the arteries from a catheter, which is inserted through a small incision in the thigh into the femoral artery and “stretched” to the heart. The method visualizes the lumen of the arteries and allows you to identify its narrowing or blockage as a result of atherosclerosis or thrombosis.
8. Angiography is an X-ray examination of the lumen of a certain artery by introducing contrast into it to identify stenosis, occlusion, thrombosis or aneurysm, and developmental pathology.

If necessary, ventriculography is prescribed. This is visualization of the cavities of the heart through x-ray examination with preliminary introduction of contrast into them - to identify septal defects, cardiac aneurysms, and signs of cardiomyopathies.

On a note! Transesophageal echocardiography is an ultrasound examination of the heart through a probe inserted into the esophagus to detect a blood clot in the atrium, septal defects, and valve defects.

Transesophageal electrophysiological study of the heart is the recording of an electrocardiogram through an electrode catheter inserted into the esophagus in response to stimulation of contractions - to identify various pathologies of the conduction system of the heart, which underlie many arrhythmias.

Cardiac ischemia

Main article: Coronary heart disease

Most manifestations of coronary heart disease are associated with narrowing of the coronary arteries due to atherosclerosis. As is known, the occurrence of coronary atherosclerosis is influenced by several factors: heredity, consumption of saturated fats, high blood pressure, smoking and physical activity, and the patient’s age.

Adverse workplace conditions may influence the occurrence of coronary heart disease through classical risk factors. Stressful work conditions also directly affect neurohormonal activity as well as cardiac metabolism. Coronary heart disease is manifested by the following symptoms: pain in the heart area (behind the sternum), pain radiating to the scapula, collarbone, left shoulder and forearm, little finger of the left hand, lower jaw on the left. During attacks of angina pectoris, shortness of breath, palpitations, and fatigue may occur. Coronary heart disease may be accompanied by a feeling of “fear of death,” which disappears soon after blood flow in the coronary vessel improves.

Anomalies of the coronary arteries: concept, types, pathophysiology

The term "coronary artery anomaly" refers to a wide range of congenital anomalies, including disorders of their origin, course and structure of the epicardial coronary arteries.
According to statistics, these disorders occur in less than 1% of the general population. Coronary artery anomalies often occur in association with other major congenital heart defects. This article focuses on selected coronary artery anomalies (i.e., isolated in the absence of other major congenital heart defects).

Clinical interest in coronary anomalies in adult patients stems from their occasional association with sudden death, myocardial ischemia, congestive heart failure, or endocarditis.

In addition, the presence of coronary artery anomalies can in some cases create difficulties during coronary angiography, percutaneous coronary intervention procedures, and coronary artery surgery.

The coronary arteries are the only branches of the ascending aorta that supply blood to all structures in the pericardial cavity. Typically, the two ostia of the coronary artery are located in the center of the left and right (anterior) sinuses of the aortic valve. The posterior sinus of the aortic valve does not contain the coronary ostium and is usually referred to as a non-coronary sinus.

The left coronary artery arises from an ostium located in the left coronary sinus of the aorta, and after one initial trunk (left main coronary artery) of variable length and size, it passes into the anterior interventricular branch (LAD) of the left coronary artery and the circumflex branch (OB) of the left coronary artery .

The LAD left coronary artery runs along the anterior interventricular groove, has several superficial (diagonal) and multiple deep (septal) perforating branches and, as a rule, reaches the apex of the heart.

In some individuals, the diagonal branch may have a very proximal take-off, so that the left main (LM) produces three instead of two branches. In this case, an additional artery arising from the LM arises between the LAD and OB coronary arteries and is called the intermediate coronary artery.

The left circumflex coronary artery courses in the left atrioventricular groove and usually has 1 or more branches that reach the obtuse edge of the heart (obtuse edges).

The LAD coronary artery supplies blood to the anterior wall of the left ventricle through its diagonal branches, the anterior two-thirds of the interventricular septum through its septal perforator branches, and usually the apex of the heart through its terminal branches. The OB of the coronary artery supplies blood to the lateral and posterior walls of the left ventricle through its obtuse marginal branches.

The right coronary artery (RCA) arises from the ostium located in the right coronary sinus of the aorta and passes through the right atrioventricular groove to reach the sacrum (the junction of the atrioventricular groove and the posterior interventricular groove) of the heart. It supplies blood to the inferior (diaphragmatic) wall of the left ventricle and often the posterior third of the interventricular septum, as well as the free wall of the right ventricle through its right ventricular (acute marginal) branches.

The posterior descending branch of the RCA supplies the posterior third of the interventricular septum. The posterolateral branch of the RCA supplies most of the basal portion of the posterolateral wall of the left ventricle.

Arterial dominance

The dominance of the left or right coronary artery is determined by the origin of the atrioventricular nodal artery in the region of the heart. The atrioventricular node artery arises from the RCA in approximately 90% of the population and the OB coronary artery in the remaining 10%.

The dominant coronary artery also gives rise to the posterior descending coronary artery, which passes through the posterior interventricular groove and provides branches of the septal septum to the posterior third of the interventricular septum. In individuals, both the RCA and OB together give rise to the descending coronary artery. In these cases, the coronary arterial system is called codominant.

Absence of the left main coronary artery with separate origins of the LAD and OB coronary arteries from the left coronary aortic sinus is found in approximately 1% of people who undergo angiography and is considered a normal variant.

In addition, one or more infundibular (conal) arteries may arise from a separate ostium in the aorta. In other cases of normal cardiac structure, 5 separate conal artery ostia have been reported. Small changes in the location of the orifice in the coronary sinuses of the aorta are observed quite often and have no clinical significance.

Anomalies of the coronary arteries

The list below discusses the classification of the major isolated coronary artery anomalies. As seen, coronary artery anomalies may include abnormalities in the number, origin and/or course, termination or structure of the epicardial coronary arteries.

Normal anatomy options include the following:

• Separate origin of LAD and OB from the left coronary sinus
• Minor changes in the position of the ostium in the coronary sinus
• Separate origin of conal branches

Abnormal variations regarding quantity include the following:

• RCA duplication (single or double ostium)

Anomalous discharge includes the following:

• Origin from the pulmonary trunk
• Origin from the left or right ventricle
• Origin from the bronchus / internal mammary gland / subclavian / right carotid artery / innominate artery
• High rise (more than 1 cm above the sinotubular junction)

An abnormal discharge may include the following:

• Single process: (1) from the right coronary sinus (RCA continues as OB and LAD, RCA gives off LM, RCA gives off LAD and OB) and (2) from the left coronary sinus (LM gives off LAD, OB and RCA, OB continues as RCA, OB gives to RCA, LAD gives to RCA)
• Origin of the LAD from the right coronary sinus
• Origin of the OB from the right coronary sinus
• Origin of the RCA from the left coronary sinus

Abnormal arterial endings may include the following:

• Fistulas to the right/left ventricle
• Fistulas to the right/left atrium
• Fistulas to the coronary sinus

Abnormal coronary structures include the following:

These anomalies are discussed in more detail below.

In some people, certain areas of the left ventricle may have more than one coronary artery. Cases of duplication of the LAD coronary artery, OB of the coronary artery and RCA were found.

Double anterior interventricular branch of the left coronary artery

The double LAD coronary artery consists of one short and another long artery. This anomaly can be classified into several different types.

In the most common form (type I), the short and long LAD coronary arteries arise from the normal LAD coronary artery. The shorter artery then passes through the anterior interventricular groove and ends abruptly before reaching the apex.

However, the longer artery passes along the anterior epicardial surface of the left ventricle and returns to the anterior interventricular groove in its distal third, and then continues to the apex. All diagonal branches arise from the longer artery.

In type II, the long coronary arteries of the LAD pass along the anterior surface of the right ventricle rather than the left.

In a type III double LAD coronary artery, the long artery has at least a partial intramyocardial (pontine) course. The difference from types I and II is that septal perforators arise from the long LAD, and diagonals arise from the short LAD coronary artery.

In type IV, the short LAD coronary artery arises from the LM coronary artery, and the long artery abnormally arises from the RCA and courses to the left side anterior to the right ventricular tract.

In recent years, with the increased use of coronary computed tomography angiography (CT-A), additional variants of dual LAD have been discovered.

One case described in detail a type IV variant in which an abnormal long LAD originated independently of the right coronary sinus and reached the distal anterior interventricular groove, passing through the crista supraventricularis of the retina (type V).

Duplicate right coronary artery

RCA duplication has been documented with both single and double ostia in the right coronary sinus.

The redundant vessels may pass together in the right atrioventricular groove or have separate courses with a single movement along the epicardial surface of the right ventricle.

Both blood vessels give rise to right ventricular branches, and, as a rule, the posterior descending coronary artery begins in one of them.

Disturbances in the origin of the coronary arteries followed by a normal epicardial course are associated with an abnormal location of one or both coronary ostia. These include the origin of the LM, LAD, OB or RCA from the pulmonary trunk.

Also, the coronary arteries can begin directly from the left or right ventricles; bronchial, internal mammary, subclavian, right carotid or innominate arteries; aortic arch; or descending thoracic aorta. Cases of high rise of the left or right coronary ostium, defined as the location of the ostium of the left or right coronary artery more than 1 cm above the sinotubular junction, have been reported.

Single coronary artery

The entire coronary artery system can originate from a single ostium (single coronary ostium or single coronary artery) in the aorta.

This single ostium is located in the left or right coronary sinus of the aorta.

When the LM coronary artery arises from the proximal right coronary artery, or vice versa, the anomalous artery traverses 1 of 4 aberrant pathways to reach its proper vascular territory.

Single coronary arteries may also involve the origin of the LAD and OB coronary arteries from the proximal RCA. In this option, the coronary artery of the LAD passes along one of the paths of type A, B or C, and the coronary artery of the OB - along path B or D.

Coronary artery OB can also arise from the distal RCA. In this case, the OB of the coronary artery is simply a continuation of the RCA in the posterior atrioventricular groove. A total of 20 possible variants of disorders with one coronary artery were studied.

Origin from the opposite coronary sinus

Both the left and right coronary arteries can originate from separate ostia, which are located in the same, left or right, aortic sinus. In these variants, the anomalous vessels take 1 of 4 possible paths to reach their respective territories, similar to what was described above for the single coronary artery variants.

In the absence of congenital heart defects, anomalous origin of the coronary arteries from the non-coronary sinus does not occur.

Also, normal coronary arteries may have an intramyocardial course (ie, myocardial bridging). This particular anomaly is a variable vessel length and is usually observed in the proximal portion of the LAD coronary artery.

The major epicardial coronary arteries may terminate abnormally in one of the chambers of the heart, the coronary sinus, or the pulmonary trunk, thereby leading to the formation of fistulas. Such fistulas may originate from the left coronary artery system (50-60%), the right coronary artery system (30-40%), or both (2-5%). Most fistulas (about 90%) enter the right heart.

Cases of both congenital stenosis and coronary atresia may occur. Congenital epicardial coronary artery stenosis is usually caused by a membrane or fibrous ridge.

Coronary artery atresia is characterized by the presence of a residual pit in the left or right aortic sinus, ending in an umbilical cord-shaped fibrous structure without an open lumen.

Atresia may involve individual large epicardial coronary arteries. Hypoplastic coronary arteries have a small lumen diameter (usually less than 1 mm) and reduced length. The latter is often associated with the absence of the posterior descending coronary artery.

Source: //cardio-bolezni.ru/anomalii-koronarnyh-arterij-ponyatie-vidy-patofiziologiya/

Excerpt characterizing Cardiology

– Andre, au nom de Dieu! [Andrey, for God’s sake!] – repeated Princess Marya. It was clear that Prince Andrei’s mocking attitude towards the wanderers and Princess Mary’s useless intercession on their behalf were familiar, established relationships between them. “Mais, ma bonne amie,” said Prince Andrey, “vous devriez au contraire m'etre reconaissante de ce que j'explique a Pierre votre intimate avec ce jeune homme... [But, my friend, you should be grateful to me that I explain to Pierre your closeness to this young man.] - Vraiment? [Really?] - Pierre said curiously and seriously (for which Princess Marya was especially grateful to him) peering through his glasses into the face of Ivanushka, who, realizing that they were talking about him, looked at everyone with cunning eyes. Princess Marya was completely in vain to be embarrassed for her own people. They were not at all timid. The old woman, with her eyes downcast but looking sideways at those who entered, had turned the cup upside down onto a saucer and placed a bitten piece of sugar next to it, sat calmly and motionless in her chair, waiting to be offered more tea. Ivanushka, drinking from a saucer, looked at the young people from under his brows with sly, feminine eyes. – Where, in Kyiv, were you? – Prince Andrey asked the old woman. “It was, father,” the old woman answered loquaciously, “on Christmas itself, I was honored with the saints to communicate the holy, heavenly secrets.” And now from Kolyazin, father, great grace has opened... - Well, Ivanushka is with you? “I’m going on my own, breadwinner,” Ivanushka said, trying to speak in a deep voice. “Only in Yukhnov did Pelageyushka and I get along…” Pelageyushka interrupted her friend; She obviously wanted to tell what she saw. - In Kolyazin, father, great grace was revealed. - Well, are the relics new? - asked Prince Andrei. “That’s enough, Andrey,” said Princess Marya. - Don’t tell me, Pelageyushka. “No...what are you saying, mother, why not tell me?” I love him. He is kind, favored by God, he, a benefactor, gave me rubles, I remember. How I was in Kyiv and the holy fool Kiryusha told me - a truly man of God, he walks barefoot winter and summer. Why are you walking, he says, not in your place, go to Kolyazin, there is a miraculous icon, the Mother of the Most Holy Theotokos has been revealed. With those words, I said goodbye to the saints and went... Everyone was silent, one wanderer spoke in a measured voice, drawing in air. “My father, the people came and said to me: great grace has been revealed, myrrh is dripping from the cheek of the Mother of the Most Holy Theotokos...” “Okay, okay, you’ll tell me later,” said Princess Marya, blushing. “Let me ask her,” said Pierre. -Have you seen it yourself? - he asked. - Why, father, you yourself have been honored. There is such a radiance on her face, like the light of heaven, and from mother’s cheek she keeps dripping and dripping... “But this is a deception,” said Pierre naively, who listened attentively to the wanderer. - Oh, father, what are you saying! - Pelageyushka said with horror, turning to Princess Marya for protection. “They are deceiving the people,” he repeated. - Lord Jesus Christ! – the wanderer said, crossing herself. - Oh, don't tell me, father. So one anaral did not believe it, he said: “the monks are deceiving,” and as he said, he became blind. And he dreamed that Mother of Pechersk came to him and said: “Trust me, I will heal you.” So he began to ask: take me and take me to her. I’m telling you the real truth, I saw it myself. They brought him blind straight to her, he came up, fell, and said: “Heal! “I will give you,” he says, “what the king gave you.” I saw it myself, father, the star was embedded in it. Well, I have received my sight! It's a sin to say that. “God will punish,” she instructively addressed Pierre. - How did the star end up in the image? – asked Pierre. - Did you make your mother a general? - said Prince Andrei, smiling. Pelagia suddenly turned pale and clasped her hands. - Father, father, it’s a sin for you, you have a son! - she spoke, suddenly turning from pallor to bright color. - Father, what did you say? God forgive you. - She crossed herself. - Lord, forgive him. Mother, what is this?...” she turned to Princess Marya. She stood up and, almost crying, began to pack her purse. She was obviously both scared and ashamed that she had enjoyed benefits in a house where they could say this, and it was a pity that she now had to be deprived of the benefits of this house. - Well, what kind of hunting are you doing? - said Princess Marya. “Why did you come to me?...” “No, I’m joking, Pelageyushka,” said Pierre. - Princesse, ma parole, je n'ai pas voulu l'offenser, [Princess, I'm right, I didn't want to offend her,] I just did that. Don’t think I was joking,” he said, smiling timidly and wanting to make amends. - After all, it’s me, and he was only joking. Pelageyushka stopped incredulously, but Pierre's face showed such sincerity of repentance, and Prince Andrei looked so meekly first at Pelageyushka, then at Pierre, that she gradually calmed down. The wanderer calmed down and, brought back into conversation, talked for a long time about Father Amphilochius, who was such a saint of life that his hand smelled like palm, and about how the monks she knew on her last journey to Kiev gave her the keys to the caves, and how she, taking crackers with her, spent two days in the caves with the saints. “I’ll pray to one, read, go to another. I’ll take a pine tree, I’ll go and take a kiss again; and such silence, mother, such grace that you don’t even want to go out into the light of God.” Pierre listened to her carefully and seriously. Prince Andrei left the room. And after him, leaving God’s people to finish their tea, Princess Marya led Pierre into the living room. “You are very kind,” she told him. - Oh, I really didn’t think of offending her, I understand and highly value these feelings! Princess Marya silently looked at him and smiled tenderly. “After all, I have known you for a long time and love you like a brother,” she said. – How did you find Andrey? - she asked hastily, not giving him time to say anything in response to her kind words. - He worries me very much. His health is better in winter, but last spring the wound opened, and the doctor said that he should go for treatment. And morally I am very afraid for him. He is not the type of character we women are to suffer and cry out our grief. He carries it inside himself. Today he is cheerful and lively; but it was your arrival that had such an effect on him: he is rarely like this. If only you could persuade him to go abroad! He needs activity, and this smooth, quiet life is ruining him. Others don't notice, but I see. At 10 o'clock the waiters rushed to the porch, hearing the bells of the old prince's carriage approaching. Prince Andrei and Pierre also went out onto the porch. - Who is this? - asked the old prince, getting out of the carriage and guessing Pierre. – AI is very happy! “kiss,” he said, having learned who the unfamiliar young man was. The old prince was in good spirits and treated Pierre kindly. Before dinner, Prince Andrei, returning back to his father’s office, found the old prince in a heated argument with Pierre. Pierre argued that the time would come when there would be no more war. The old prince, teasing but not angry, challenged him. - Let the blood out of your veins, pour some water, then there will be no war. “A woman’s nonsense, a woman’s nonsense,” he said, but still affectionately patted Pierre on the shoulder and walked up to the table where Prince Andrei, apparently not wanting to engage in conversation, was sorting through the papers the prince had brought from the city. The old prince approached him and began to talk about business. - The leader, Count Rostov, did not deliver half of the people. I came to the city, decided to invite him to dinner, - I gave him such a dinner... But look at this... Well, brother, - Prince Nikolai Andreich turned to his son, clapping Pierre on the shoulder, - well done, your friend, I loved him! Fires me up. The other one speaks smart things, but I don’t want to listen, but he lies and inflames me, an old man. Well, go, go,” he said, “maybe I’ll come and sit at your dinner.” I'll argue again. “Love my fool, Princess Marya,” he shouted to Pierre from the door. Pierre only now, on his visit to Bald Mountains, appreciated all the strength and charm of his friendship with Prince Andrei. This charm was expressed not so much in his relationships with himself, but in his relationships with all his relatives and friends. Pierre, with the old, stern prince and with the meek and timid Princess Marya, despite the fact that he hardly knew them, immediately felt like an old friend. They all already loved him. Not only Princess Marya, bribed by his meek attitude towards the strangers, looked at him with the most radiant gaze; but little, one-year-old Prince Nikolai, as his grandfather called him, smiled at Pierre and went into his arms. Mikhail Ivanovich, m lle Bourienne looked at him with joyful smiles as he talked with the old prince. The old prince went out to dinner: this was obvious to Pierre. He was extremely kind to him both days of his stay in Bald Mountains, and told him to come to him. When Pierre left and all the family members came together, they began to judge him, as always happens after the departure of a new person, and, as rarely happens, everyone said one good thing about him. Returning this time from vacation, Rostov felt and learned for the first time how strong his connection was with Denisov and with the entire regiment. When Rostov drove up to the regiment, he experienced a feeling similar to the one he experienced when approaching the Cook's House. When he saw the first hussar in the unbuttoned uniform of his regiment, when he recognized the red-haired Dementyev, he saw the hitching posts of red horses, when Lavrushka joyfully shouted to his master: “The Count has arrived!” and shaggy Denisov, who was sleeping on the bed, ran out of the dugout, hugged him, and the officers came to the newcomer - Rostov experienced the same feeling as when his mother, father and sisters hugged him, and the tears of joy that came to his throat prevented him from speaking . The regiment was also a home, and the home was invariably sweet and dear, just like the parental home. Having appeared before the regimental commander, having been assigned to the previous squadron, having gone on duty and foraging, having entered into all the small interests of the regiment and feeling himself deprived of freedom and shackled into one narrow, unchanging frame, Rostov experienced the same calm, the same support and the same consciousness the fact that he was at home here, in his place, which he felt under his parents’ roof. There was not all this chaos of the free world, in which he did not find a place for himself and made mistakes in the elections; there was no Sonya with whom it was or was not necessary to explain things. There was no option to go there or not to go there; there were no 24 hours of the day that could be used in so many different ways; there was not this countless multitude of people, of whom no one was closer, no one was further; there were no these unclear and uncertain financial relations with his father, there was no reminder of the terrible loss to Dolokhov! Here in the regiment everything was clear and simple. The whole world was divided into two uneven sections. One is our Pavlograd regiment, and the other is everything else. And there was nothing else to worry about. Everything was known in the regiment: who was the lieutenant, who was the captain, who was a good person, who was a bad person, and most importantly, a comrade. The shopkeeper believes in debt, the salary is a third; there is nothing to invent or choose, just don’t do anything that is considered bad in the Pavlograd regiment; but if they send you, do what is clear and distinct, defined and ordered: and everything will be fine.

Treatment methods

A repeated consultation with a cardiologist (after the doctor receives the diagnostic results) usually ends with the prescription of a set of medications. The dosage regimen and doses are calculated individually, depending on the patient’s condition, diagnosis, and the presence of other health problems.

A good doctor will definitely tell you about additional therapy measures. Many heart diseases require restriction of activity. At the same time, gentle physical activity is recommended for patients. In addition to drug therapy, cardiologists often recommend exercise therapy and nutritional adjustments.

If the pathology is not treated conservatively (with the use of medication and physiotherapy, exercise therapy) and requires surgical intervention, the doctor will refer you to another specialist - a cardiac surgeon.

Provoking factors

In the modern world, there is a sharp increase in the number of people with cardiological problems and it is very sad that the age of patients is significantly younger, and the mortality rate is increasing every year
. Experts consider the following predisposing factors to be the main reasons for such dismal statistics:

• the accelerated pace of modern life, which completely disrupts the proper rhythm of work and rest, which leads to rapid wear and tear of the heart and becomes a precedent for knowing who a cardiologist is and what he does;
• constant stress and psycho-emotional tension provokes spasms of the heart vessels, which threatens the sudden development of a heart attack;
• food rich in animal fats contributes to the early development of atherosclerosis;
• the abundance in the daily menu of foods enriched with simple carbohydrates, which provoke the development of obesity and diabetes, that is, diseases that force a person to soon find out who a cardiologist is;
• unfavorable environmental conditions have a detrimental effect on the condition of the myocardium;
• the presence of inflammatory foci in the body (chronic tonsillitis, phlegmonous course of a purulent-septic process) can provoke the development of infectious lesions of the heart;
• some chronic diseases contribute to the development of cardiovascular problems (hepatitis, cirrhosis, thyroid disorders);
• long-term vitamin deficiency or hypovitaminosis of vitamins B, C, K, E and minerals such as zinc, calcium, potassium, magnesium in most cases becomes a reason to find out what a cardiologist is treating;
• congenital heart pathologies require lifelong monitoring by a cardiologist.

In each individual case, at the appointment the cardiologist performs a general examination of the patient and prescribes an individual diagnostic and treatment plan.

. Very often, the effectiveness of therapeutic measures in cardiac patients depends on consultations with related specialists such as a therapist, rheumatologist, resuscitator, and cardiac surgeon.

A versatile approach to treatment, aimed at the cause of the disease, significantly increases the survival rate, improves the life prognosis and prevents the progression of the pathological process.

Comprehensive examination

Not every heart disease can be diagnosed using electrocardiography (ECG). Patients of our clinic have access to the full range of diagnostic measures for a high-quality examination of the functioning of the heart and blood vessels. We offer the following paid services:

• Echocardiography (ultrasound examination of blood vessels and heart);
• 24-hour blood pressure monitoring and ECG Holter monitoring;
• spirography;
• fundus examination;
• laboratory diagnostics (biochemistry, CBC, OAM);
• Ultrasound examination of the abdominal cavity;
• consultations with related specialists (neurologist, rheumatologist, etc.).