STENOCARDIA is a symptom of acute myocardial ischemia, which is expressed by an attack of chest pain. In most cases, angina refers to the manifestations of coronary heart disease and is identified as one of its clinical forms. The classification of angina pectoris is based on the peculiarities of its course.
For the first time arisen angina. To this form conditionally carry stenocardia within 6 weeks from the moment of occurrence of the first attack. In this case, the first attack may be the only one or during this period the seizures are repeated and by the end of the 6th week angina can be assessed as stable or progressive.
Stable angina is characterized by periodic occurrence of pain attacks under specific conditions, in particular, at a certain level of physical activity, depending on which four functional classes of stable angina are distinguished: Class I - attacks occur only under extreme physical exertion and quickly pass independently after its termination; II class - seizures occur at the usual load for the patient (for example, when walking on an even place over a distance of more than 500 m, with a quiet climb up the stairs to more than one floor) or are provoked by a pronounced psychoemotional stress; The likelihood of attacks increases in the morning, in cold windy weather; Pain is often stopped only by taking nitroglycerin; III class - seizures are provoked even by insignificant physical exertion, the pain appears when walking calmly on an even place for a distance not exceeding 500 m, with a slow rise to one floor; IV class - attacks occur with minimal physical exertion (getting up from a chair, torso bending with the putting on of shoes, slow walking on an even place for a distance of up to 100 m), and also at rest (especially at night), sometimes when the patient moves from a vertical position to a horizontal (Which is associated with a short-term increase in the work of the heart due to an increase in the venous influx).
Progressing angina. It is characterized by frequent, prolonged and increased intensity of pain attacks (often with a significant decrease in the effectiveness of nitroglycerin), a relatively rapid transition of angina to a higher functional class. Progressive angina does not always, though often, result in the development of myocardial infarction.
Spontaneous, or special, angina pectoris (sometimes referred to as variant angina pectoris) is characterized by the appearance of anginal attacks without apparent connection with any external provoking factors; Attacks proceed more heavily and more durable than with stable angina pectoris, are more resistant to the action of nitroglycerin.
The pathogenesis of angina pectoris in its initial stages coincides with the pathogenesis of acute coronary insufficiency, which is based on the discrepancy between the possibilities of delivering blood to the myocardium through stenotic or spasmodic coronary artery and its needs in oxygen and nutrients that increase due to physical exertion or pronounced psychoemotional stress. In the origin of nocturnal attacks of angina pectoris, coronarospasm plays the role; Suggest also the role of amplification of vagal influences at night. The pathogenesis of a painful attack, i.e. Angina itself, is associated with irritation of the endings of sensitive fibers of the sympathetic nerves of the heart with substances released by ischemia from myocardial cells. Impulses are sent to the ganglions of the cervicothoracic region, penetrate the spinal cord, spreading to the zones of somatic innervation, reach the subcortical structures and the cerebral cortex, forming a sensation of pain with localization in the innervation zones from the upper thoracic segments. The sometimes observed disappearance of angina after myocardial infarction is explained by the destruction of nerve endings in the necrosis zone.
Clinical picture . With angina pectoris, a painful attack occurs during a physical (sometimes emotional) load and usually passes 1-2 min after it stops. The duration of a severe attack can reach 20 - 30 minutes, with a longer duration, as a rule, focal dystrophic or necrotic lesions of the myocardium develop. In the vast majority of cases, the pain is located deep behind the sternum, most often at the level of the upper third of the sternum. Sometimes the zone of the most severe pain is shifted somewhat to the left or to the right of the median line. Patients define pain as constrictive, pressing, sometimes as lomiting, bursting or burning. The intensity of pain varies: from hard to difficult to barely expressed, comparable with the feeling of discomfort. Irradiation of pain is not always observed; In typical cases, pain radiates to the left shoulder, the left arm, the foreleg (less characteristic of right-sided irradiation) or in the neck, lower jaw, interscapular space. Seldom there is an atypical irradiation of pain - in epigastrium, the left half of the celiac region. At the time of the attack the patient, as a rule, freezes; If the pain occurred while walking, he stops. Objectively, with a severe attack, there may be hyperemia or pallor of the face, the appearance of sweat droplets on it, sometimes increased sweating on the trunk, a slight tachycardia , a slight increase or decrease in blood pressure, and dilatation of the pupils. The intake of nitroglycerin in the vast majority of cases completely stops the attack within 1-2 minutes.
With spontaneous angina, there is no link between a pain attack and physical exertion. In a number of patients, as in many patients with angina of exertion, seizures are provoked by psychoemotional stress. Attacks of spontaneous angina characterized by a long duration (for 15 - 20 minutes), often with ventricular extrasystole. The effectiveness of nitroglycerin for arresting the attack is low, pain is more easily cured by nifedipine (corinfar, adalate, kordafen), a tablet (or capsule) which should be chewed and kept in the mouth until it is completely absorbed.
The course of angina pectoris largely depends on the severity and rate of progression of coronary artery disease, underlying the coronary insufficiency. In some cases, the functional class of angina may remain unchanged for many years, in others a slow but steady increase in symptoms is observed. Angina of any functional class, like the first one, can, for not always known reasons, suddenly acquire a rapidly progressive course and end with myocardial infarction.
The diagnosis is based on the connection of a painful attack with a load or other provoking factor, a paroxysmal character of the pain syndrome with a clear beginning and end of the attack, a relatively short duration, a quick (usually within 2 min) cupping action of nitroglycerin. Additional signs - the nature of pain, its localization and irradiation - can vary.
Despite the fact that in the vast majority of cases, angina is quite typical, to date, the errors associated with its hyper- or hypodiagnosis are widespread. Pain in the chest can be associated with many diseases or pathological conditions (pericarditis, pleurisy , myalgia and myositis , plexitis , neuritis , neuralgia , esophagitis, diaphragmatic hernia, shingles , etc.). However, for all these conditions, the pain is not clearly paroxysmal, it is not associated with such forms of exercise as walking or climbing the stairs (with lesions of the nervous system or musculoskeletal system, it can arise or increase with certain movements, for example, turning the trunk, raising hands ), Is not inferior to the action of nitroglycerin.
To confirm the diagnosis, a number of special methods are used. If it is possible to register a standard ECG at the height of a pain attack, then in most cases a characteristic ischemic (horizontal or skewed) depression of the ST segment is found, which confirms the diagnosis. For this purpose, daily ECG monitoring is also used.
Diagnosis uses methods based on the artificial provocation of an attack of angina pectoris. The bicycle ergometric test with a dosed stepwise increasing load is sufficiently informative. The appearance of ST-segment depression during the trial objectifies the diagnosis. More physiological is used mainly in hospitals load test on a treadmill (treadmill) with varying speed of its movement and angle of inclination. With some concomitant diseases bicycle ergometry or treadmill test is impossible or the results of these tests are difficult to interpret. In such cases, transesophageal electrical stimulation of the atria is performed in cardiac hospitals with a smooth increase in the stimuli until the heart rate is reached, at which the ECG changes appear characteristic of ischemia. To verify the diagnosis of spontaneous angina, the most informative is continuous continuous ECG monitoring using portable instruments, which is also used for the diagnosis of angina pectoris. In the latter case, at the time of an attack, a horizontal or skewed displacement of the ST segment downward from the isoelectric line is recorded; And in the classical form of spontaneous angina (Prinzmetal's stenocardia) there is a transient elevation of the ST segment.
Treatment of angina includes urgent measures to stop the attack and the constant implementation of medical recommendations to patients aimed at reducing the frequency and severity of angina attacks.
Coping an attack with stable angina reduces to an immediate cessation of physical activity and the mandatory intake of nitroglycerin tablets under the tongue, even if the patient knows from his own experience that the pain passes through the termination of the load. The need for nitroglycerin is dictated by the fact that the initial subjective manifestations of an anginal attack can not predict how it will flow and whether it will go into an anginal status. The most convenient and effective tablet form of nitroglycerin; Its action reaches a maximum even after 1 - 1.5 minutes after ingestion under the tongue. If taking one tablet of nitroglycerin did not stop the pain, after 2 to 3 minutes you need to take a second pill; While the patient should take the position lying or reclining. If nitroglycerin causes a very severe headache, you can recommend that the patient always carry a certain stock of sugar pieces, each of which is moistened with 6-8 drops of a 0.1% solution of nitroglycerin in a 3% alcohol solution of menthol (a drop of Votchal), and when pain occurs, rassasyvat Such a piece. Many patients prefer to take validol, but it is much less effective than nitroglycerin . If the nitroglycerin is poorly tolerated, it is advisable to try to stop seizures by resorbing a tablet of nitrosorbide (10 mg) or chewing a corinth tablets (10 mg). The latter is a means of choice for arresting an attack of spontaneous angina, in which nitroglycerin is less effective.
With progressive angina, a painful attack is attempted to be suppressed by all available means. Without waiting for the pain to intensify, it is necessary to immediately take a nitroglycerin tablet under the tongue and, if this is not enough, you need to take 2 - 3 more pills with intervals between each intake of about 2 minutes. The total daily dose of nitroglycerin is not limited. If nitroglycerin is ineffective for 15-20 minutes, narcotic analgesics (promedol, omnopon , morphine, fentanyl) are injected parenterally. Rapidly progressive angina, including the first arising, is an absolute indication for urgent hospitalization. Scheduled hospitalization is indicated in severe angina pectoris of stress III-IV functional class for the selection of therapy or the solution of the issue of surgical treatment.
The constant treatment of patients with angina is largely carried out under the subjective control of the patient himself, who must therefore be properly informed about the nature of the disease and the criteria for assessing its course, the tactics of behavior in cases of exacerbations and remissions of the disease. The patient should be told about the conditions in which the occurrence of an anginal attack is most likely, to emphasize that the disease has a chronic course and requires constant treatment. It is necessary in an accessible form, trying not to intimidate the patient, to explain to him that with a sharp increase in the frequency, elongation and increase in the severity of seizures, as well as when. The development of their insensitivity to nitroglycerin, he must immediately seek emergency medical help.
For the treatment of stable angina pectoris, a large number of medicinal products belonging to various chemical and pharmacological groups have been proposed. The most common drugs were found in three groups: nitrates, beta-adrenergic receptor blockers and calcium ion antagonists.
Of nitro drugs for the prevention of angina attacks, the use of extended-release nitroglycerin dosage forms for parenteral use in the form of a patch, ointment, buccal plates, etc. is widely used. Such drugs as sastak , nitron , and sostanit are ineffective, because the nitroglycerin contained in them is almost completely destroyed when passing through the liver. For oral administration, isosorbide dinitrate preparations (nitrosorbide, isodinite-retard, cardiacet, etc.), isosorbide-5-mononitrate (isomac, etc.) are effective. Doses of these drugs fluctuate widely, they are selected taking into account the clinical effectiveness. The main disadvantage of nitrates is a gradual decrease in their effectiveness during long-term use ("addiction"), which, according to some data, is less inherent in medicinal forms for application on the skin (nitromazy, nitroplastri) or gum (trinitrolong). Nitrosorbide, the effect of a single dose of which lasts 4-b h, it is recommended to take at least 4 times a day (10 - 80 mg per reception), prolonged forms of nitrates should be taken 2 times a day. It is close to nitro drugs for pharmacological action and in some cases replaces them molsidomine , which is administered orally 1-4 mg 3-4 times a day. All nitro drugs can cause severe headache. In such cases, treatment starts with minimal doses, which gradually increase. It is advisable for 2 - 3 weeks before the beginning of treatment with nitro preparation to take the administration of drops Votchal on sugar (starting with 1-2 drops on a piece of sugar and gradually bringing a single dose to 8-10 drops 4 times a day). With angina pectoris I-II functional classes, nitrates are used only "on demand" for relief of attacks of pain; III-IV functional classes - prolonged forms of drugs are taken continuously.
Effective for the treatment of angina beta-adrenoblockers, reducing the need for myocardium in oxygen and increasing the tolerance of patients to physical exertion. Very important for the treatment of patients with angina pectoris and such properties of beta-blockers as their antiarrhythmic and antifibrillatory action, the ability in many cases to reduce elevated blood pressure. The most widely used anaprilin (propranolol, indiral, obzidan) in doses of 10 to 40 mg 4-6 times a day. With angina pectoris, anaprilin is prescribed 4 times a day. Anaprilin refers to nonselective beta-adrenoblockers, the use of which is contraindicated in bronchospasm, as well as with obliterans and angioneurotic diseases of the extremity vessels (atherosclerosis, endarteritis, Raynaud's disease, etc.). These contraindications are less significant for the so-called cardioselective drugs of this group, whose action in usual doses is limited to the blockade of predominantly beta-adrenergic receptors of the myocardium (in large doses the selectivity of action decreases). Selective beta-adrenoblockers include metoprolol (spesicore), atenolol . The longer duration of action has atenolol (0.05-0.1 g of the drug is sometimes enough to take once a day), somewhat less long-acting metoprolol ( 0.025-0.1 g 2 times a day). If these drugs cause a pronounced bradycardia, it is advisable to try beta-blockers with a so-called internal sympathomimetic action, for example, the sectal, which very rarely slows down and may even increase the rate of heartbeats. All beta-adrenoblockers are able to inhibit atrioventricular conduction, so treatment with them, especially at first, should be done under electrocardiographic control (additional oppression of impaired conductivity may be absent). It is extremely important to consider that the sudden discontinuation of beta-adrenoblockers can cause withdrawal syndrome-a sharp exacerbation of angina and even the development of myocardial infarction, therefore, if necessary, the dose is reduced gradually, while supplementing the drug therapy with drugs from other groups.
Of the drugs belonging to the group of calcium antagonists, verapamil (isoptin, finaptin) and nifedipine (corinfar) are most often used. Verapamil has moderate antiarrhythmic activity and is preferred for the combination of angina with cardiac arrhythmias. He is prescribed in a dose of 80-120 mg 3 - 4 times a day (isoptin-retard - once a day), and after 2 - 3 months after the start of treatment, the dose can be gradually reduced, bringing it to 160-120 g per day. Treatment with verapamil in high doses requires electrocardiographic control, since atrioventricular conduction may be suppressed. Nifedipine in a dose of 10 to 20 mg 3-4 times a day is a means of choice in the treatment of spontaneous angina pectoris, in which nitro drugs are less effective, and the appointment of beta-blockers, according to some authors, is undesirable because of their possible contribution to the development of angiospasm. With angina pectoris, a long-acting drug from the same group of amlodipine (norvask) is used, which is prescribed at 5-10 mg per day.
As an antiplatelet agent used acetylsalicylic acid (aspirin), the use of which 0.125 g once a day significantly reduces the risk of development in patients with myocardial infarction.
Treatment of patients with progressive angina is performed only in a hospital with a more strict than usual restriction of the motor regime (the loads causing angina attacks should be completely excluded). Recommended fractional food, a diet containing easily digestible foods. It is important to monitor the regularity of the stool, if necessary, use laxatives and enemas, as straining during defecation often causes a severe attack of angina pectoris. Doses of antianginal drugs are increased to the maximum tolerated by patients. To prevent myocardial infarction must appoint acetylsalicylic acid. In many cases, a positive effect results in the use of heparin under the control of blood coagulation. Gradual reduction of doses of antianginal drugs and expansion of the motor regime are permissible only after regression of symptoms and stabilization of the condition.
Forecast . Stable exertional angina often for many years does not tend to progress. Patients with angina pectoris I-II functional class, as a rule, can perform work that does not require physical stress. With a new and progressive angina, the prognosis is uncertain; Progressive angina in more than half of cases is completed by the development of myocardial infarction. Surgical treatment for angina pectoris III-IV functional class can improve the prognosis.
Prevention coincides with the prevention of coronary heart disease. Creation of conditions for the development of collateral circulation in the system of coronary arteries of the heart is facilitated by exercise therapy (especially dosed walking). Patients with stable angina pectoris are recommended daily walking (5-10 km) at a rate that does not cause seizures. It is very important to exclude smoking , but for long-term smokers, this should be done with caution, since if a patient who has been smoking 20 cigarettes a day or more for many years immediately stops smoking, possibly sharp exacerbation of the disease and even the development of myocardial infarction. In such cases, it is advisable to reduce the number of cigarettes smoked each day (cigarettes) gradually. It is not allowed to abuse alcohol.