Stable angina( tension, angina pectoris) - Causes, symptoms and treatment. MF.

In order for the human heart to fully pump blood through the body, it needs an additional food system. In the blood supply of the heart, this system is represented by the left and right coronary arteries, originating from the aortic arch, enveloping the heart from all sides and penetrating into the myocardium in the form of a network of minute capillaries. These arteries supply the heart muscle with blood and oxygen continuously, and during physical exertion with increasing heart rate, the flow of blood to the heart increases, allowing it to pump more blood to the skeletal muscles and internal organs.

But an adequate increase in coronary blood flow occurs only under the condition of healthy, elastic, free in the luminal coronary arteries. If the internal wall of the arteries is affected by atherosclerosis, that is, an atherosclerotic plaque forms inside the artery, then a partial or complete occlusion( occlusion) of the lumen of the vessel occurs, and the blood can no longer flow to the heart muscle. Plaques consist of lipids( fats) inside and connective tissue from the outside. Calcium salts can be deposited in the plaque, making it even denser and interfering with the flow of blood, and clots can be formed when the plaque capsule is cut( dissection), which further covers the lumen. With a decrease in blood flow to the myocardium due to ischemia, cardiac muscle cells( myocytes) suffer, their oxygen starvation( hypoxia) develops, which can lead to necrosis, that is, the death of a part of the cells. The released products of the exchange of damaged cells are captured by the receptors in the heart, then a signal is sent to the brain and a person has a feeling of pain.

Atherosclerotic plaque is the cause of the development of ischemia( reduction of blood supply) of the myocardium.

The described processes are typical for ischemic heart disease. IHD includes certain diseases, united by this common term. These include angina pectoris, myocardial infarction, postinfarction cardiosclerosis and some other diseases.

Angina is a clinical manifestation of myocardial ischemia in the form of painful attacks. Earlier, angina was divided into stress angina( arising at physical exertion) and resting angina( at rest), at present the terms stable and unstable angina are used.

Unstable angina is characterized by the progression of myocardial ischemia and requires timely treatment to the doctor with hospitalization in the hospital, since in the absence of treatment is often complicated by the development of myocardial infarction.

Stable angina( angina pectoris) is a combination of clinical symptoms caused by a lack of oxygen in the heart muscle and manifested by pressing pains in the heart area. It is characterized by the appearance of pain during physical activity( therefore, it was called tension angina), which is successfully stopped when the load is stopped or nitroglycerin is taken, and is divided into functional classes depending on the volume of the load that provokes the pain. Angina develops with a narrowing of the lumen of the vessel by more than 50%.

Causes of stable angina

The main causes of the disease are atherosclerotic lesions of the inner walls of the coronary arteries, their spasm( contraction), as well as increased activity of the blood coagulation system with the formation of thrombi in the coronary arteries. Also, stable angina may develop with heart defects, for example, with aortic stenosis, with hypertrophic cardiomyopathy, as there is an increase in the mass of the heart muscle, which requires an increase in cardiac vessels and an increase in coronary blood flow, but these requirements are not implemented.

The risk factors for angina pectoris include:

- age - people over 45-50 years old suffer more often, but there is a constant tendency to the fact that diseases are getting younger, and heart diseases including. In recent years, angina is often seen in people younger than 40 years old
- sex - most men suffer from angina pectoris, especially up to 45-50 years, which is related to the hormonal background in women before menopause - women's hormones have "protective" properties in relation to cardio-
vascular system - race -
is more likely to have a disease in Europe - heredity plays an important role, especially if close relatives have heart disease or a family has had deaths in mage due to cardiac causes
- obesity contributes to increased heart burden, as well as general body detenity associated with sedentary lifestyle
- lipid metabolism disorders, including cholesterol, help to reduce the level of "good" and increase the level of "bad" cholesterol inblood and deposition of it on the walls of the vessels
- arterial hypertension accompanies vasospasm with an increased load on the heart muscle
- smoking causes a prolonged spasm of blood vessels, including
- Diabetes mellitus is characterized by damage to the vessels of the microvasculature( capillaries), including the heart, resulting in spasms, vascular wall disturbances with increased adhesion( attachment) of platelets, and clots of

. Not only psychoemotional andphysical loads( significant or not), but also provoking factors such as cold weather, abundant food intake followed by a sharp load, rapid climbing the stairs, walkingba against a strong wind or other moments that may cause any discomfort in the patient.

Symptoms of stable angina

The main manifestation of the disease is pain syndrome. The criteria for anginous( stenocardic) pains are as follows:

- are characterized by compressive, pressing, burning
- located behind the sternum or in the left side of the thorax
- can be irradiated to the left scapula, arm, neck, lower jaw, or may bewithout irradiation or localization only in the interscapular area of ​​the
- arise with physical activity, walking, climbing the ladder
- lasting for several minutes, no more than 10 - 15 minutes
- pass alone at rest when the load stops or theare taken with nitroglycerin intake under the
tongue - can be accompanied by fear of death and autonomic disturbances - sweating, dizziness, lack of air

The figure indicates the possible localization of pain in angina

Pain in angina does not change its intensity at the height of a deep breath, unlike intercostal neuralgia, whichthe patients themselves with osteochondrosis of the spine can take for pain in the heart( with neuralgia, the pain on inspiration is increased).

Similar burning pains behind the breastbone can occur with gastroesophageal reflux, when there is a reverse casting of acidic gastric contents into the esophagus. This disease requires a more detailed examination of the patient. When reflux pain is associated with eating and there is a need to drink solid food with water.

It is important for the patient to remember that if pains in the heart occurred for the first time in his life, there was an increase in the frequency, intensity and duration of pain attacks, an intense pain attack developed, with no effect on nitroglycerin, he should immediately consult a doctor( in the clinic or ambulance), as possible the development of unstable angina or myocardial infarction.

Depending on the level of physical exertion causing pain, stable angina is classified into functional classes( FC):

I FC - seizures occur very rarely, with significant, unfamiliar loads of the
II FC - the patient can go more than 500 meters without pain,climb more than 2 floors
III FC - the patient can pass less than 500 m, climb only to the first floor without pain
IV FC - there is a restriction of the usual daily activity due to frequent attacks of pain in the heart

Classification into classes is important in order to determine the correct tactics of treatment, since at III and IV FC, when seizures often recur and interfere with a full-fledged lifestyle, the long-acting nitrates are prescribed daily or before exercise( for example, before walking for a long time).

Diagnosis of stable angina

It is possible to suspect the diagnosis already in the process of questioning the patient and detailing complaints of heart pain associated with the load. When examined, there are no abnormalities in the severity of the patient's condition. Overweight can be observed, up to a high degree of obesity, high blood pressure, swelling of the legs and feet. Pathological tones and heart murmurs can be heard in the presence of heart defects, congestive wheezing in the lungs - with chronic heart failure.

General laboratory tests of blood and urine, a biochemical blood test( liver and kidney function tests, cholesterol levels should be no more than 4.5 mmol / L), hormonal blood tests( eg, thyroid hormones with dyshormonal cardiomyopathy) are prescribed from laboratory examination methods;Studies of the glycemic profile in individuals with diabetes mellitus.

From instrumental diagnostic methods are shown:
- standard ECG.In the absence of pain in the heart may be of little informative, since often signs of ischemia are not recorded during the inter-attack period. With the removal of the ECG at the time of pain, ST segment depression, negative teeth T

ECG of the patient during an attack of angina are recorded.

- daily monitoring of the ECG according to Holter is designed to detect painless episodes of myocardial ischemia, and also establishes a connection with physical activity due to the patient's diary, where he indicates the time of the onset of pain, notes periods of physical activity, sleep and rest periods,
food intakewith physical exertion - treadmill test( treadmill) and veloergometry( "bicycle").Assigned to assess the amount of physical activity that provokes pain attacks and confirms a particular functional class of
- PEPI can be shown when it is impossible to conduct samples with a load and is based on electric stimulation of the heart through the esophagus with an increase in heart rate, which can provoke the development of an attack
- echocardiography- CG, ultrasound of the heart) is used to assess stroke volume, ejection fraction, total contractility of the myocardium, can reveal zones of hypo- and akinesia( reduced and absentmyocardial ischemia), which indicates the sites of myocardial ischemia
- Echo-KG stress can be prescribed with little information in the standard Echo-CG and is performed by visualization of the heart after physical exertion.
- coronaroangiography is the "gold" standard for diagnosing IHD.It allows to assess the presence of atherosclerotic lesions of the coronary arteries, the degree of narrowing of the vessels, the need for surgical intervention. Carried out by the introduction of radiopaque material into the coronary vessels with subsequent X-ray images

Treatment of stable angina

Therapy of the disease includes general measures, medication and cardiosurgery.
The general measures are reduced to modification of a way of life, correction of the raised figures of arterial pressure, appointment of sedative preparations of a phytogenesis( valerian, St. John's wort, Leonurus).Sometimes these activities in patients with I FC are enough to cause bouts of pain ceased to bother for a long time.

Drug treatment for stable angina pectoris consists in the appointment of the following drug groups:

- beta adrenoblockers ( atenolol, carvedilol, propranolol idr).Assigned to reduce heart rate, reduce vascular tone, reduce the load on the heart muscle and reduce its oxygen demand. In the absence of contraindications( bronchial asthma, chronic obstructive pulmonary disease) are taken daily.
- nitrates are peripheral vasodilators, dilate the coronary arteries and veins, reducing the flow of blood to the heart and the load on the heart muscle. Short-acting drugs are taken to stop painful attacks in the form of tablets( nitroglycerin) and aerosol( nitromite, nitrospray).Begin to act after 1 - 2 minutes, the duration of the action is not more than 15 minutes. Long-acting drugs( isosorbide, cardiac, monochinke) are used to prevent attacks of angina in patients with III-IV FC daily or before physical exertion.
- calcium channel antagonists ( amlodipine, verapamil) reduce the burden on the heart, reducing vascular tone and blood pressure. In the presence of contraindications to betablockers can be taken daily.
- antiplatelet agents ( thrombotic Ass, aspiric, aspirin cardio) are prescribed to prevent aggregation of platelets and their deposition on atherosclerotic plaques. Covered with an enteric film that protects the stomach wall from the irritating effect of aspirin. They are taken daily after meals once a day.
- lipid-lowering medications ( lovastatin, atorvastatin, rosuvastatin) lower cholesterol levels in the blood, preventing further formation of new plaques. They are taken once a day at night.
- ACE inhibitors ( perindopril, quadripril) are used to correct arterial hypertension and to protect blood vessels, kidneys, brain, and heart from high blood pressure in the vessels.

Surgical methods of treatment include:

- coronary artery stenting - installation in the artery of a metal structure - a stent that mechanically extends the vessel
- balloon angioplasty of the coronary arteries. It is carried out by insertion through the femoral vein of a catheter with a balloon at the end, widening at the site of the constriction of the vessel and a "crushing" plaque, so that the patency of the artery is restored. After angioplasty, stenting can be performed immediately due to the frequent development of restenosis( repeated constrictions) after it.
- aorto-coronary bypass - creating a shunt between the aorta and the affected artery, avoiding the narrowing of the

. Indications for surgery include inefficiency of drug therapy, anginahigh functional class in young adults, critical narrowing of the artery lumen( more than 75%), postinfarction angina and others. Indications and contraindications are determined by the attending physician on an individual basis.

Lifestyle with stable angina

The lifestyle modification is as follows:
- overweight control
- smoking and alcohol abstinence
- proper nutrition - fast food, sharp, salty, fatty, fried, spicy dishes are forbidden. Welcome dairy, cereals, vegetables, fruits, low-fat varieties of meat, poultry, fish. Limits animal fats, sugar, salt, confectionery
- moderate physical activity
- exclusion of significant physical exertion and stress
- compliance with adherence to treatment, that is, regular intake of prescribed medications for the prevention of angina attacks and complications, especially in persons withdiabetes mellitus

Complications of stable angina

In the absence of treatment, angina may progress due to the further formation of atherosclerotic plaques on the eyevessels. This can lead to the development of unstable angina, acute myocardial infarction, sudden cardiac death.

Prevention of complications is the timely access to a doctor in case of pain in the heart or in the case when the pain syndrome lasts longer and stronger in intensity. To prevent the development of formidable complications will help to take prescribed medications that slow the progression of atherosclerosis and IHD.

Forecast

The prognosis of stable angina in the absence of complications is relatively favorable. Mortality is low and is 2 - 3% per year from the total number of patients with angina pectoris - this group includes those who developed a fatal myocardial infarction.

If a myocardial infarction or other complications develops, the prognosis is determined by the severity of the developed disease. The use of beta-blockers, nitrates and antagonists of calcium channels helps to significantly reduce the frequency of seizures and the risk of complications.

Doctor therapist Sazykina O.Yu.