Angina pectoris - Causes, symptoms and treatment. MF.

Based on coronary heart disease lies deposition on the walls, or rather, in the walls, coronary arteries of atherosclerotic plaques, which, like "scum on a teapot", narrows the lumen of the vessel. Plaques gradually reduce the lumen of the arteries, which leads to inadequate nutrition of the heart muscle. The process of formation of atherosclerotic plaques is called atherosclerosis. The speed of its development is different and depends on many factors. You already know these risk factors.

Coronary arteries play a crucial role in the vital activity of the heart muscle. The blood flowing through them, brings oxygen and nutrients to all cells of the heart. If the arteries of the heart are affected by atherosclerosis, then in conditions where there is an increased need of the heart muscle in oxygen( physical or emotional stress), there may be a state of myocardial ischemia - insufficient supply of blood to the heart muscle. This condition - the heart signal about oxygen deficiency and there is angina. Thus, angina is not an independent disease, it is a symptom of ischemic heart disease. In the people this condition was called "angina pectoris".

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Angina variants

There are several variants of angina, or more precisely three:

Stable angina , which includes 4 functional classes depending on the load being transferred.

Unstable angina , stability or unstable angina is determined by the presence or absence of a connection between the load and the manifestation of angina pectoris.

Variable angina , or angina of Prinzmetalla. Another type of angina is called vasospastic.

It should be noted that in the year angina is fixed in 0.2 - 0.6% of the population with a prevalence of it in men aged 55 - 64 years, it occurs in 30,000 - 40,000 adults per 1 million population per year, and the prevalence of envy from sexand age. Before myocardial infarction, stable angina was observed in 20% of patients, after myocardial infarction - in 50%.

Stable angina:

It is believed that for the onset of angina, the arteries of the heart should be narrowed because of atherosclerosis by 50 - 75%.If treatment is not performed, then atherosclerosis progresses, plaques on the walls of the arteries are damaged. They form thrombi, the lumen of the vessel tapers even more, the blood flow slows down, and angina attacks increase and arise with mild physical exertion and even at rest. Stable angina( tension), depending on the severity, is usually divided into functional classes:

I functional class - attacks of chest pain occur rarely. Pain occurs with an unusually large, quickly performed load.
II functional class - seizures develop with rapid ascent of stairs, fast walking, especially in frosty weather, in cold wind, sometimes after eating.
III functional class - a pronounced restriction of physical activity, seizures appear during normal walking up to 100 meters, sometimes immediately when going out into the street in cold weather, when climbing to the first floor, can be provoked by unrest.
VI functional class - there is a sharp restriction of physical activity, the patient becomes unable to perform any physical work without manifestations of angina attacks;it is characteristic that there can develop attacks of angina of rest - without the previous physical and emotional load.

The selection of functional classes allows the physician to choose the right medicines and the amount of physical activity in each case.

Unstable angina:

If habitual angina changes its behavior, it is called unstable or pre-infarction. What is it? Under unstable angina, the following conditions are understood:

For the first time arisen in the life of angina, not more than one month old;

Progressive angina when there is a sudden increase in frequency, severity or duration of seizures, the appearance of nocturnal seizures;

Stenocardia of rest - the appearance of attacks of angina at rest;

Postinfarction angina pectoris - the appearance of rest angina in the early post-infarction period( 10-14 days after the onset of myocardial infarction).

In any case, unstable angina is the absolute indication for admission to the intensive care unit. URGENTLY HAVE QUICK HELP! !!

How to distinguish between stable and unstable angina?

Stable angina

Unstable angina

Attack of

is provoked by the same level of physical activity

is provoked by less physical exertion or at rest

Attack time

less than 15 minutes

longer but less than 15 minutes

Nitroglycerin

helps 1 tablet

helps poorly, you need more than 1 tablet

Variable angina:

Symptoms of variant angina arise as a result of sudden contraction( spasm) coronaryth arteries. Therefore, this type of angina is called vasospastic angina pectoris. With this angina, coronary arteries can be affected by atherosclerotic plaques, but sometimes they are absent. Variant angina occurs at rest, at night or early in the morning. The duration of the symptoms is 2-5 minutes, nitroglycerin and calcium channel blockers, such as nifedipine, are helpful.

Symptoms of angina

Stenocardia are characterized by feelings of compression, severity, raspiraniya, burning behind the sternum, arising from physical exertion. Pain can spread to the left arm, under the left scapula, in the neck. Less often the pain is given to the lower jaw, the right half of the chest, the right arm, to the upper abdomen.

The duration of an attack of angina is usually several minutes. Since pain in the heart often occurs during movement, a person is forced to stop. In connection with this, angina is figuratively called the "disease of the shop window reviewers", after a few minutes of rest the pain usually passes.

A painful attack with angina persists more than one, but less than 15 minutes. The onset of pain is sudden, directly at the height of physical exertion. Most often, such a load is walking, especially in cold winds, after a plentiful meal, while climbing the stairs.

The end of the pain, usually occurs immediately after a decrease or complete cessation of physical activity or 2-3 minutes after taking nitroglycerin under the tongue.

Symptoms associated with myocardial ischemia, but different from a pain attack - equivalents of angina - a sense of lack of air, difficulty in inspiration. Dyspnea occurs in the same conditions as the chest pain.

Angina in men usually manifests as typical bouts of chest pain. Women, elderly people and patients with diabetes mellitus during myocardial ischemia may not experience any pain, but feel a frequent heartbeat, weakness, dizziness, nausea, increased sweating. Some people with ischemic heart disease, during myocardial ischemia( and even myocardial infarction) do not experience any symptoms at all. This phenomenon is called painless, "dumb" ischemia.

What lies behind the pain in the chest?

It should be remembered that chest pain can occur not only with angina pectoris, but also in many other diseases. In addition, at the same time there may be several causes of pain in the chest. Let's figure this out.

Under angina may be masked:

Myocardial infarction;

Diseases of the gastrointestinal tract( peptic ulcer, diseases of the esophagus);

Diseases of the chest and spine( osteochondrosis of the thoracic spine, shingles);

Lung diseases( pneumonia, pleurisy).

Remember that only the doctor can determine the cause of pain in the chest.

Stenocardial equivalents

In addition to pain, signs of angina may be the so-called equivalents of angina pectoris. These include:

shortness of breath - a feeling of difficulty in breathing, both on inhaling and exhaling. Dyspnoea occurs due to a violation of heart relaxation

marked and severe fatigue during exercise is a consequence of insufficient supply of oxygen to muscles due to reduced contractility of the heart.

Risk of developing angina

Risk factors are characteristics that contribute to the development, progression and manifestation of the disease.

Many risk factors play a role in the development of angina pectoris. Some of them can be influenced, others can not. Those factors that we can influence are called removable or modifiable, to which we can not - irremovable or unmodifiable.

Unmodified. Unavoidable risk factors are age, gender, race and heredity. Thus, men are more prone to developing angina pectoris than women. This trend persists to approximately 50-55 years, that is, before the onset of menopause in women, when the production of female sex hormones( estrogens), which have a pronounced "protective" effect on the heart and coronary arteries, is significantly reduced. After 55 years, the incidence of angina in men and women is approximately the same. There is nothing to be done with such a distinct tendency as the increase and burden of diseases of the heart and blood vessels with age. In addition, as noted, the race affects the incidence of disease: Europeans, or more precisely those living in the Scandinavian countries, suffer from angina and arterial hypertension several times more often than those of the Negroid race. The early development of angina often occurs when the ancestors of a patient in the male line have suffered a myocardial infarction or died of a sudden cardiac disease to 55 years, and the direct relatives of the female line had a myocardial infarction or sudden cardiac death up to 65 years.

Modifiable. Despite the impossibility to change neither his age nor his gender, a person is able to influence his condition in the future, eliminating removable risk factors. Many of the removable risk factors are interrelated, therefore, eliminating or decreasing one of them, you can eliminate the other. Thus, lowering the fat content in food leads not only to lowering blood cholesterol levels, but also to weight loss, which, in turn, leads to lower blood pressure. Together, this helps reduce the risk of angina pectoris. And so we list them.

Obesity is an excessive accumulation of adipose tissue in the body. Over half of the people in the world over the age of 45 are overweight. What are the causes of excess weight? In the overwhelming majority of cases, obesity is of alimentary origin. This means that overweight causes overeating with excessive consumption of high-calorie, especially fatty foods. The second most important cause of obesity is insufficient physical activity.

Smoking is one of the most important factors in the development of angina pectoris. Smoking with a high degree of probability promotes the development of IHD, especially if combined with an increase in the level of total cholesterol. On average, smoking shortens life by 7 years. Smokers also increase the carbon monoxide content in the blood, which leads to a decrease in the amount of oxygen that can enter the cells of the body. In addition, nicotine, contained in tobacco smoke, leads to spasm of the arteries, thereby leading to an increase in blood pressure.

An important risk factor for angina is diabetes. In the presence of diabetes, the risk of angina and coronary heart disease increases on average by more than 2 times. Patients with diabetes often suffer from coronary heart disease and have a worse prognosis, especially with the development of myocardial infarction. It is believed that with the duration of overt diabetes for 10 years and more, regardless of its type, all patients have a fairly pronounced atherosclerosis. Myocardial infarction is the most common cause of death in diabetic patients.

Emotional stress can play a role in the development of angina pectoris, myocardial infarction, or lead to sudden death. With chronic stress, the heart begins to work with increased workload, blood pressure rises, oxygen and nutrient delivery to organs worsens. To reduce the risk of cardiovascular disease from stress, it is necessary to identify the causes of its occurrence and try to reduce its impact.

Hypodinamy or lack of physical activity is rightfully called the disease of the XX, and now the XXI century. It is another disposable risk factor for cardiovascular disease, so it is important to be physically active to maintain and improve health. In our time in many spheres of life there is no need for physical labor. It is known that IHD is 4-5 times more common in men under the age of 40-50 years who were engaged in easy labor( compared to those who do heavy physical work);in athletes, the low risk of angina and IHD persists only if they remain physically active after leaving the big sport.

Arterial hypertension is well known as a risk factor for angina and ischemic heart disease. Hypertrophy( increase in size) of the left ventricle as a consequence of arterial hypertension is an independent strong prognostic factor of mortality from coronary disease.

Increased blood clotting. Coronary artery thrombosis is the most important mechanism of myocardial infarction formation and circulatory insufficiency. It also promotes the growth of atherosclerotic plaques in the coronary arteries. Disturbances predisposing to increased formation of thrombi are risk factors for the development of complications of angina and coronary artery disease.

Metabolic Syndrome.

Stresses.

Stenocardia prophylaxis

Methods for the prevention of angina pectoris are similar to the prevention of coronary heart disease.

How to identify angina without additional tests

Clinical manifestations of the disease( complaints) should be evaluated. Pain sensations in angina have the following features:

character of pain: sensation of compression, severity, raspiraniya, burning behind the sternum;

their localization and irradiation: painful sensations are concentrated in the sternum, often pain radiates to the inner surface of the left hand, to the left shoulder, scapula, neck. Less often the pain is "given" to the lower jaw, the right half of the thorax, the right arm, to the upper abdomen;

duration of pain: pain attack with angina persists more than one, but less than 15 minutes;

conditions for the onset of a pain attack: the onset of pain is sudden, immediately at the height of physical activity. Most often, such a load is walking, especially against the cold wind, after a plentiful meal, while climbing the stairs;

factors facilitating and / or arresting pain: the reduction or disappearance of pain occurs almost immediately after the reduction or complete cessation of exercise or 2-3 minutes after taking nitroglycerin under the tongue.

Typical Angina:

Injured pain or discomfort of characteristic quality and duration
Occurs during physical exertion or emotional stress
Passes at rest or after taking nitroglycerin.

Atypical angina:

Two of the above signs.

Non-cardiac pain:

One or none of the above symptoms.

What laboratory tests should be done?

The minimum list of biochemical indicators for suspected ischemic heart disease and angina includes the determination of blood levels:

total cholesterol;

high-density lipoprotein cholesterol;

low-density lipoprotein cholesterol;

triglycerides;

of hemoglobin;

glucose;

AST and ALT.

Which instrumental diagnostic methods need to be passed?

The following studies are the main instrumental methods for the diagnosis of stable angina:

electrocardiography,

exercise test( bicycle ergometry, treadmill),

echocardiography,

coronary angiography.

Note. If it is not possible to conduct a sample with physical exertion, as well as to identify the so-called Bozboleva ischemia and variant angina pectoris, a daily Holter monitoring of the ECG is indicated.

Coronary angiography is the "gold standard" in cardiology.

Coronary angiography( or coronary angiography) is a method for diagnosing the state of the coronary bed. It allows to determine the localization and degree of narrowing of the coronary arteries.

The degree of constriction of the vessel is determined by the reduction in the diameter of its lumen in comparison with the proper one and is expressed in%.To date, a visual assessment has been used with the following characteristic: normal coronary artery, modified arterial contour without stenosis, narrowing & lt;50%, narrowing by 51-75%, 76-95%, 95-99%( subtotal), 100%( occlusion).Essential is the narrowing of the artery & gt;50%.Hemodynamically insignificant is the narrowing of the lumen of the vessel & lt;50%.

In addition to the localization of the lesion and its degree, coronary angiography may reveal other characteristics of artery involvement, such as thrombus, tearing( dissection), spasm, or myocardial bridge.

Absolute contraindications for coronary angiography at present does not exist.

The main tasks of coronary angiography:

specification of the diagnosis in cases of insufficient informative value of the results of non-invasive examination methods( electrocardiography, 24-hour ECG monitoring, physical stress tests and others);

determination of the possibility of restoration of adequate blood supply( revascularization) of the myocardium and the nature of the intervention - coronary artery bypass grafting or angioplasty with coronary stenting.

Coronarography is performed to resolve the issue of the possibility of myocardial revascularization in the following cases:

severe angina pectoris III-IV functional class, persisting with optimal therapy;

signs of severe myocardial ischemia based on non-invasive methods( electrocardiography, 24-hour ECG monitoring, bicycle ergometry and others);

presence in a patient of an anamnesis of episodes of sudden cardiac death or dangerous ventricular rhythm disturbances;

disease progression( according to the dynamics of non-invasive tests);

questionable results of non-invasive tests in persons with socially significant occupations( public transport drivers, pilots, etc.).

Emergency care for angina attack

An ambulance should be called if this is the first time in a life attack of angina, and if:

chest pain or its equivalents intensifies or lasts more than 5 minutes, especially if all this is accompanied by a worsening of breathing, weakness, vomiting;

chest pain did not stop or intensified within 5 minutes after resorption of 1 tablet of nitroglycerin.

Help with pain before the arrival of the "First Aid" with an attack of angina

Conveniently put the patient with his legs down, soothe him not to let him get up. Give chew 1/2 or 1 large tablet of aspirin( 250-500 mg).For relief of pain, give nitroglycerin - 1 tablet under the tongue or nitrolingival, the isoket in the aerosol container( one dose under the tongue, not breathing).In the absence of effect, use the indicated preparations repeatedly. Nitroglycerin in tablets can be re-used at intervals of 3 min, aerosol preparations - at intervals of 1 minute. Repeated use of drugs can be no more than three times because of the danger of a sharp drop in blood pressure.

Treatment of angina pectoris

Main goals in the treatment of patients with angina pectoris:

detection and treatment of diseases worsening the course and clinical manifestations of angina,

eliminating atherosclerosis risk factors,

improving the prognosis and preventing complications( myocardial infarction or sudden cardiac death).

decrease in the frequency and intensity of angina attacks to improve quality of life.

For this, 3 treatment methods are simultaneously used:

lifestyle change and non-drug treatment,

selection of adequate drug therapy,

myocardial revascularization: coronary angioplasty or coronary artery bypass grafting aimed at coronary blood flow restoration.

Note. The choice of method of treatment depends on the clinical response to the initial medication, although some patients immediately prefer and insist on coronary revascularization.

Drug therapy for angina

Medications that improve the prognosis( recommended for all patients with angina in the absence of contraindications):

is an antiplatelet drug. They interfere with the aggregation of platelets, that is, prevent thrombogenesis at its earliest stage.
Acetylsalicylic acid is used to prevent thrombus formation. It is proved that taking aspirin prevents the development of angina and thrombosis. The main disadvantage of long-term use of aspirin is the possibility of developing side effects from the gastrointestinal tract, such as heartburn, stomach pain, gastritis, etc. Therefore, doctors recommend taking the drug in a special enteric coating. For example, Trombo ACC does not do any harm to the stomach, as its film shell dissolves only in the small intestine. The drug contains the optimal dose of acetylsalicylic acid, which is easily digested in the body and does not harm the digestive system. To prevent the occurrence of a stroke, the drug should be taken continuously and for a long time. Duration of admission is determined by the attending physician.

Note. Prolonged regular intake of acetylsalicylic acid( aspirin) by patients with angina pectoris, especially those who underwent myocardial infarction, reduces the risk of recurrent myocardial infarction by an average of 30%.

is beta-blockers( Metaprolol, Atenolol, Bisaprolol and others).By blocking the effect of stress hormones on the cardiac muscle, they reduce the need for myocardium in oxygen, thereby balancing the imbalance between myocardial oxygen demand and its delivery through the narrowed coronary arteries.

are statins( simvastatin, atorvastatin and others).They reduce the level of total cholesterol and cholesterol of low-density lipoproteins, provide a reduction in mortality from cardiovascular diseases and increase life expectancy.

are angiotensin-converting enzyme inhibitors( Perindopril, Enalapril, Lysinopril and others).Admission of these drugs significantly reduces the risk of death from cardiovascular diseases, as well as the likelihood of developing heart failure.

Antianginal( antiischemic) therapy aimed at reducing the frequency and intensity of angina attacks:

is beta-blockers( Metaprolol, Atenolol, Bisaprolol and others).The intake of these drugs reduces the heart rate, systolic blood pressure, the reaction of the cardiovascular system to physical stress and emotional stress. This leads to a decrease in myocardial oxygen consumption.

is a calcium antagonist( Verapamil, Diltiazem).They reduce myocardial oxygen consumption. However, they can not be prescribed in the syndrome of weakness of the sinus node and the violation of atrioventricular conduction.

is nitrates( nitroglycerin, isosorbide dinitrate, isosorbide mononitrate).They perform expansion( dilatation) of veins, thereby reducing preload on the heart and, as a consequence, the need for myocardium in oxygen. Nitrates eliminate the spasm of the coronary arteries.

Note. To date, the uselessness of using such groups of drugs as vitamins and antioxidants, female sex hormones, riboxin, ATP, cocarboxylase has been known to be useless.

Coronary( balloon) angioplasty

Coronary( balloon) angioplasty is an invasive method of restoring the blood supply( revascularization) of the myocardium.

In the course of coronary angioplasty, a special catheter under local anesthesia is inserted through the femoral artery and is conducted to the site of the narrowing of the coronary artery. At the end of the catheter is a canister, which( in the deflated state) is placed in the lumen of the vessel directly at the level of the atherosclerotic plaque. With the subsequent expansion of the balloon, it crushes the plaque, thereby restoring the disturbed blood flow. The size of the can is selected in advance in accordance with the size of the affected vessel and the length of the narrowed section( according to data previously performed by coronary angiography).Restoration of blood flow is confirmed by control coronary angiography.

Coronary( balloon) angioplasty can be combined with other effects: the installation of a metal framework - an endoprosthesis( stent), burning a plaque with a laser, destroying a plaque with a rapidly rotating drill, and cutting a plaque with a special catheter.

Indication for coronary angioplasty is high-grade angina pectoris, which is not amenable to drug therapy, with a significant lesion of one or more coronary arteries.

The effectiveness of coronary angioplasty is obvious - angina attacks cease, the contractile function of the heart improves. However, recurrence of the disease due to the development of repeated constriction of the artery( restenosis) occurs in about 30-40% of cases within 6 months after the intervention.

Aorto-coronary shunting

Aorto-coronary bypass surgery is an operative procedure performed to restore the blood supply to the myocardium below the site of the atherosclerotic narrowing of the vessel. This creates a different pathway for the blood flow( shunt) to the area of the heart muscle, the blood supply of which has been disturbed.

Surgical intervention is performed in severe angina pectoris( III-IV functional class) and narrowing of the coronary artery lumen & gt;70%( according to the results of coronary angiography).Shunting is subject to the main coronary arteries and their large branches. Previously transferred myocardial infarction is not a contraindication to this operation. The volume of the operation is determined by the number of affected arteries supplying the viable myocardium with blood. As a result of the operation, the blood flow should be restored in all zones of the myocardium, where blood circulation is disturbed. In 20-25% of patients who underwent aorto-coronary bypass surgery, angina pectoris resumes within 8-10 years. In these cases, the question of re-operation is being considered. Note. In patients with diabetes mellitus, prolonged occlusions( obstruction) of the arteries, lesion of the main trunk of the left coronary artery, the presence of pronounced narrowing in all three major coronary arteries, preference is usually given to aorto-coronary bypass, rather than balloon angioplasty.

Angina pectoris test

The test is aimed at the timely detection of angina pectoris. Please carefully read the questions and answer them, recording the number of points for each answer, taking into account the sign( +) or( -).The sum of all the answers will give the result of the test.

1 Age:
1 - to 35 years old
2 - 35 - 45
3 - 46 - 55
4 - 56 - 65
5 - 65 years and over male
-3
0
+3
+ 7
+9 women
-7
-3
+1
+5
+8

2 Duration of pain attacks in the chest area: 1 - several seconds
2 - up to 15 minutes
3 - up to 30 minutes
4 - more than one hour +1
+4
+2
-3

3 Pain: 1 - blunt noisy
2 - stitching
3 - burning
4 - compressive, pressing +2
-1
+2
+4

4 Pain occurs mostMore often: 1 - when climbing a mountain, climbing stairs, fast walking
2 - for walking, minimum load
3 - at rest, sitting, lying in bed
4 - with agitation and nervous strain +7

+3

-3
+2

5 Pain localization: 1 - behind the sternum
2 - in the neck and jaw region
3 - left front part of the chest
4 - right front chest
5 - left arm
6 - other location +4
+4
+3
-1
+2
-3

6 What does the patient do when the bol appearsin the chest: 1 - takes nitroglycerin, validol
2 - stops
3 - slows down movement
4 - continues walking +5
+5
+3
-2

7 If the patient stops or takes nitroglycerin: 1 - the pain disappears
2 - the pain does not disappear
3 - the patient does not stop and does not take nitroglycerin +7
-3

0

8 How quickly pain disappears: 1 - up to 5 minutes
2 - up to 10 minutes
3 - in more than 10 minutes +10
+5
-2

Test results:

The score of answers to all questions is less than 22 - no angina .

The score of answers to all questions is within 22-28 - angina is doubtful, additional examination of is required.

The sum of the answers to all questions is 29 or more - angina pectoris with a probability of 90-95% .

Angina pectoris and outcome of the disease

Angina is chronic. Attacks can be rare. The maximum duration of an attack of angina pectoris is 20 minutes, may result in myocardial infarction. In patients with long-term angina, cardiosclerosis develops, cardiac rhythm is broken, symptoms of heart failure appear.

Cessation of an attack of angina

immediately stop physical activity;

to dissolve under the tongue a tablet of nitroglycerin;

adopt a semi-sitting position( if there is no severe weakness and sweating)

provide access to fresh air.

Treatment of unstable angina is carried out in a hospital.

Treatment of stable angina

The choice of treatment tactics, prescription of medicines is performed only by the attending physician!

Correction of lipid spectrum of blood( medicines and / or extracorporal hemocorrection procedures).

Prevention of thrombosis( continuous aspirin and / or extracorporeal hemocorrection procedures).

Prevention of pain attacks( preparations from the group of β-blockers, nitrates, calcium antagonists, etc.).

Surgical methods of treatment - stenting, angioplasty of the coronary arteries, coronary artery bypass graft.

Treatment of angina with folk remedies

Alternative medicine offers for the treatment of angina in addition to herbs the Buteyko method( respiratory gymnastics), which has proved itself well enough in the treatment of cardiovascular diseases. It is not recommended to treat angina pectoris alone, it is desirable to use folk prescriptions for angina pectoris only in parallel to the main treatment under the supervision of a doctor.