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In the initial stage of diabetes, the course of atherosclerosis is latent. In this regard, the allocation of the preclinical period of atherosclerosis is justified. During this period, changes at the biochemical level are possible. In the blood plasma, three main classes of lipids are determined: cholesterol and its esters, trnglcerides, phospholipids. Of great clinical importance is the determination of blood cholesterol in HDL, LDL, VLDL.
HDL with electrophoresis on paper along with a-globulins, LDL moves with b-globulins, VLDL - on paper are between a-LP and b-LP. The results are evaluated by the level of the cholesterol coefficient: this is the ratio of the sum of LDL cholesterol and VLDL to HDL cholesterol. This coefficient can be calculated using another formula: the ratio of the difference between total cholesterol and HDL cholesterol to HDL cholesterol. In healthy men of 30 years, it is 2, 5, in men aged 40-60 years without symptoms of coronary heart disease - 3-3.5. In patients with coronary artery disease, the atherogenic coefficient reaches values of 4-6.
During the period of clinical manifestations, aspects of atherosclerosis are considered as the main direct consequences in the form of: coronary heart disease, angina pectoris, myocardial infarction, atherosclerotic cardiosclerosis, sudden death, coronary artery disease (acute cerebrovascular accident, ischemic encephalopathy, coronary artery disease, atherosclerosis , ischemic limb disease). In the clinic of diabetic macroangiopathies, coronary heart disease, which obstructs atherosclerosis of the vessels of the lower extremities and acute cerebrovascular accidents, is of the greatest importance.
The most common cause of coronary artery disease in patients with diabetes is atherosclerotic lesion of the coronary arteries. There is a narrowing of the arteries, blood flow decreases, myocardial ischemia occurs. Inadequate supply of myocardium with oxygen and nutrients leads to a violation of the most important functions: mechanical, biochemical, electrophysiological.
Transient ischemia is manifested in patients with diabetes with attacks of angina pectoris, prolonged attacks of ischemia can lead to the appearance of necrosis of the myocardial site. A typical symptom in coronary heart disease is an angina pectoris. In this case, the patient complains of discomfort or pain behind the sternum of various intensities. The pain is increasing-decreasing in nature, increases with physical exertion, stress, exposure to cold air. Typical irradiation of pain in the left arm, left shoulder. Pain relief occurs within 5 minutes by sublingual administration of nitroglycerin.
With an objective examination, usually during an attack of angina pectoris, you can detect slight tachycardia, signs of autonomic lability, mixing of the boundaries of relative cardiac dullness to the left, with auscultation, 1 tone at the apex can be weakened, in the II intercostal space on the right - accent 2 tones.
An electrocardiographic study helps to verify the diagnosis: the shift of the ST segment and the inversion of the T wave will be recorded.
In difficult cases, ECG is recorded during exercise, daily monitoring. Ultrasound examination allows you to indirectly confirm coronary heart disease, in particular, areas of hypo-, akinesia, damage to the valve apparatus are revealed.
To study stenosis of the coronary arteries, an invasive method is used - coronarography. IHD is described in more detail in the literature specifically devoted to this topic. Persons with diabetes have several features of the course of coronary heart disease. These patients have a high frequency of painless forms of coronary heart disease and myocardial infarction, which is explained by the presence of diabetic iyuropathy. This necessitates not only glycemic control, but also ECG recording for any "difficult to explain" deterioration in the condition of these patients. In addition, in patients with diabetes mellitus, daily monitoring of ECG should be used as widely as possible in order to detect painless ischemia.
In patients with diabetes mellitus, IHD is detected with the same frequency in women and men in all age groups, myocardial infarction in them develops 2-4 times more often than in the general population, often has a complicated, recurrent course. Hospital mortality from myocardial infarction in patients with diabetes is 2 times higher than in individuals without impaired carbohydrate metabolism.
In atherosclerosis of the arteries of the lower extremities, patients with diabetes complain of "intermittent claudication", which manifests itself during exercise in the form of fatigue, paroxysmal pain, cramps in the legs, usually passing during rest. To progress the atherosclerotic process leads to the appearance of these symptoms at rest. Pain at rest is manifested by symptoms of intense burning in the foot and may be accompanied by a violation of sensitivity and movement.
With an objective examination, the hallmark is a weakening or disappearance of the pulse on the dorsal artery of the foot, pallor of the lower extremities with an elevated position of the limb, thickening of the nails, hair loss, skin atrophy. The skin on the leg is cold flabby, hypotrophy of the limb is noted, the development of gangrene is possible. During auscultation, vascular murmurs can be heard due to turbulence in blood flow in aneurysmal and stenotically modified arteries.
Acute limb ischemia is manifested by “5 P” syndrome: Pulselessness, Pain, Pallor, Paresthesia, Paralysis (lack of pulse, pain, pallor, impaired sensitivity and motor functions). When Doppler ultrasound reveals stenosis, assess the condition of the collaterals. Atherosclerosis of the vessels of the lower extremities is a common finding in patients with diabetes mellitus. The most severe clinical manifestation of damage to leg arteries in patients with diabetes mellitus is the ischemic and neuroischemic form of diabetic foot syndrome.
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