Angina pectoris (angina pectoris)

Angina pectoris (chest angina) - attacks of sudden pain in the chest due to an acute shortage of blood supply to the myocardium - a clinical form of ischemic heart disease.

Pathogenesis. In most cases, angina is caused by atherosclerosis of the coronary arteries; The initial stage of the latter limits the expansion of the lumen of the artery and causes an acute shortage of blood supply to the myocardium with considerable physical or (and) emotional overstrain; Sharp atherosclerosis, narrowing the lumen of the artery by 75% or more, causes such a deficit even at moderate stresses. The appearance of an attack is facilitated by a decrease in the flow of blood to the coronary arteries (arterial, especially diastolic hypotension of any, including medicinal origin, or a drop in cardiac output in tachyarrhythmia, venous hypotension); Pathological reflex influences from the biliary tract, esophagus, cervical and thoracic spine with accompanying diseases; Acute narrowing of the lumen of the coronary artery (non-structuring thrombus, swelling of atherosclerotic plaque). The main mechanisms of subsidence collapse: rapid and significant decrease in the level of cardiac muscle work (termination of the load, the action of nitroglycerin), restoration of the adequacy of blood flow to the coronary arteries. The main conditions for reducing the frequency and stopping seizures: adaptation of the patient's load regime to the reserve capabilities of its coronary bed; Development of ways of roundabolism of the myocardium; Stihanie manifestations of concomitant diseases; Stabilization of systemic circulation; The development of myocardial fibrosis in the area of ​​his ischemia.

Symptoms, course. With angina, pain is always characterized by the following symptoms:

1. Has the nature of an attack, i.e., it has a clearly expressed time of onset and termination, remission;

2. Occurs under certain conditions and circumstances;

3. Begins to subside or completely ceases under the influence of nitroglycerin (1-3 min after its sublingual administration). Conditions for the onset of angina pectoris: most often walking (pain during acceleration, climbing uphill, with a sharp headwind, walking after a meal or with a heavy burden), but also a different physical effort, or (and) considerable emotional stress . The conditioning of pain by physical effort is manifested in the fact that when it continues or increases, the intensity of pain inevitably increases, and when the effort ceases, the pain subsides or disappears within a few minutes. These three features of pain are sufficient to establish a clinical diagnosis of an attack of angina and to distinguish it from various pain sensations in the heart and in the chest, which are not angina pectoris.

Recognition of angina frequently occurs at the first treatment of the patient, whereas for the deviation of this diagnosis, it is necessary to monitor the course of the disease and to analyze the data of repeated inquiries and examinations of the patient. The following symptoms complement the clinical characteristics of angina pectoris, but their absence does not exclude this diagnosis:

1. Localization of pain behind the breastbone (most typical!), Rarely - in the neck, lower jaw and teeth, in the hands, in the forehead and scapula (more often on the left), in the region of the heart;

2. The nature of the pain - pressing, compressing, less often burning (like heartburn) or the sensation of a foreign body in the chest (sometimes the patient may experience a painful and painful sensation behind the sternum and then denies the presence of pain proper);

3. Simultaneous with an attack of increasing blood pressure, pallor of the covers, sweating, fluctuations in the pulse rate, the appearance of extrasystoles. All this characterizes the angina of tension. The thoroughness of the medical questioning determines the timeliness and correctness of the diagnosis of the disease. It should be borne in mind that often the patient, experiencing typical angina pectoris, does not report them to the doctor as "not related to the heart," or, on the contrary, fixes attention on the diagnostic secondary feelings "in the heart area."

The angina of rest, unlike the stoocardia of tension, arises out of connection with physical effort, more often at night, but otherwise retains all the features of a severe attack of the angina pectoris and is often accompanied by a feeling of lack of air, suffocation.

In most patients, the course of angina is characterized by relative stability. By this we mean a certain prescription for the appearance of signs of angina pectoris, whose attacks during this period changed little in frequency and strength, occur when the same ones are repeated, or when similar conditions occur, are absent outside these conditions and subsided in resting conditions (angina of stress) or after administration Nitroglycerin. The intensity of stable angina is characterized by the so-called functional class (FC). To the IFC include people who have stable angina pectoris manifested by rare attacks caused only by excessive physical stress. If attacks of stable angina occur and with normal loads, although not always, such angina is referred to as IIPK, and in the case of seizures with small (household) loads - to III FC. IV FC is fixed in patients with seizures with minimal loads, and sometimes in the absence of them.

Angina pectoris should alert the doctor if: the attack occurred for the first time, but in particular - if the newly acquired seizures become more frequent and worse from the first weeks of the illness; The course of angina pectoris loses its stability: the frequency of seizures increases, they arise in conditions other than before (with lower stresses, strains), appear outside stresses (at rest, in the early morning), as if they pass from I - II FC to III - IV FC; That is, the course of angina changed, acquiring essentially new characteristics. ECG changes (ST segment reduction, T wave inversion, arrhythmia), as well as a slight increase in serum enzyme activity (CK, LDH, LDG1, ASAT) are usually absent in such cases, but the presence of these signs further confirms the instability of angina pectoris. Pre-infarction angina does not always result in a heart attack (the probability of a heart attack is about 30%); This must be taken into account in clinical diagnosis.

Occasionally, there is a so-called variant (vasospastic) form of angina characterized by spontaneous character of the attack, recorded on the ECG by abrupt elevations of the ST segment, refractory to beta-blockers (anaprilin and obzidan), but sensitivity to calcium ion antagonists (verapamil, phenygidine, corinfar).

The basis for the diagnosis of any of the forms and variants of the course of angina pectoris is a correctly constructed and carefully conducted interrogation of the patient. In unclear cases, a physical exercise test is carried out (bicycle ergometric test) to identify a hidden coronary insufficiency. The tactics for establishing a diagnosis is determined by the following schematic sequence of solving the main questions: the coronary (anginal) nature of pain? Are there signs of pre-infarction angina? Is the present exacerbation during ischemic heart disease associated with the influence of non-cardiac (concomitant) diseases? Only a convincingly reasoned negative answer to the first of the three questions gives the right to seek another cause (source) of pain: the finding of another disease as a source of pain in the patient can not exclude the presence of angina pectoris as manifestations of coronary heart disease simultaneously. For pain in the heart region of non-stenocardial nature, see Cardialgia.

Complications of actual angina pectoris is not observed if it does not become an expression of the progression of cardiosclerosis and if it does not appear to be the first manifestation of a developing myocardial infarction. Therefore, angina pectoris, which lasts for 20 - 30 minutes, as well as unstable angina pectoris require an electrocardiographic examination within the next few hours (day) and determining the presence of reactive shifts in the activity of a number of enzymes in the blood, body temperature (see Myocardial Infarction).

Treatment. Causing an attack: a calm, preferably sitting position of the patient; Nitroglycerin under the tongue (1 tablet or 1 - 2 drops of 1% solution on a piece of sugar, on a tablet of validol), repeated taking of the drug after no effect in 2 to 3 minutes; Corvalol (valocardin) - 30 - 40 drops inside with a sedative purpose; Arterial hypertension during an attack does not require emergency medicinal measures, since the decrease in blood pressure occurs spontaneously in the majority of patients; If nitroglycerin is poorly tolerated (a bursting headache), then a mixture of 9 parts of 3% menthol alcohol and 1 part of 1% nitroglycerin solution is prescribed for 3 to 5 drops on sugar at the reception.

General principles of treatment: suggestion to the patient to avoid the stresses leading to an attack, to use nitroglycerin without fear, to take it "prophylactically" in anticipation of a tension fraught with an attack; Elimination of emotional stress, including fear caused by anxiety, in connection with the disease (psychotherapeutic effects, the appointment of tranquilizers; see "Psychotropic drugs in somatic medicine"); Treatment of concomitant diseases, especially of the digestive system; Measures to prevent atherosclerosis; Preservation and gradual expansion of the limits of physical activity (taking into account the functionality of the patient).

Treatment in the interictal period: rare attacks of angina (FC 1) - nitrates (nitrosorbide 10 - 20 mg per reception) in anticipation of significant loads. Angina pectoris FC 11 requires the constant admission (for years!) Of beta-adrenergic receptor blockers (anaprilin, obzidan, etc.); Their dose is individual (from 10 to 40 - 60 mg per 1 reception), it is highly desirable to take 4, and not 3 times a day (now there are preparations of prolonged action), the last time after 3 to 4 hours before going to bed ; While the heart rate should be reduced to 60 - 70 per 1 min (it is not counted according to the ECG taken off at rest, but only in the active state of the patient!). Nitrates (nitromazine, nitrosorbide, trinitrolong, etc.) should be used systematically, and after the seizures stop (stabilization of the course) - just before the loads (a trip around the city, emotional stress, etc.); Nitrosorbide is taken 10 - 0 mg 4 - 6 times a day (the effect of the drug lasts 2.5 - 3 hours); Nitrol ointment is applied to the skin every 4 to 6 hours (4 to 5 hours), including immediately before going to bed.

Treatment of angina in the period of its unstable course:

1. Providing patient rest; Hospitalization in a specialized cardiological institution (department);

2. Nitrates - constantly in / in or in the form of ointments - see Myocardial infarction;

3. Heparin therapy - 1000 units per hour IV drip continuously 2 - 3 days or p / k in the fiber of the anterior abdominal wall 5,000 units 4 times a day;

4. Necessarily acetylsalicylic acid for 100 - 200 mg once a day (before noon) after eating;

5. Reception of beta-blockers to continue (their patients, as a rule, already take);

6. Sedative drugs psychotherapeutic effect.

Antagonists of calcium ions are prescribed:

1. In addition, at occurrence of attacks of a stenocardia in rest, in night and in a pre-dawn hours, and also in the morning, before a food intake; With a tendency to bradycardia (pulse less often 60 - 55 in 1 min), interfering with increasing the dose of beta-blockers, when required;

2. Isolated - in return for the contraindicated to the patient beta-blockers. In the first case, usually 30-40 mg of Corinfar per day, taken in the evening, at night, early in the morning; In the second case, the daily dose of corinphore is increased to a level providing an antianginal effect (if bradycardia is absent, then verapamil 40 mg 4-6 times per day is also suitable).

With stenocardia FC P and above - stopping the use of antianginal drugs (especially beta-blockers - the phenomenon of "recoil!"), Even for a short period of time is not justified and therefore impractical.

There is also treatment of concomitant diseases - hypertension, digestive system diseases, etc.

The prognosis in the absence of complications is relatively favorable. The ability to work remains, but with the restriction of work that requires considerable physical effort.