Angina pectoris

Risk factors

Diagnostics

Treatment of angina pectoris

Angina pectoris is a disease caused by a mismatch between the oxygen demand of the myocardium and its delivery, leading to impaired cardiac function.

The leading cause of development in 95–98% of all cases is atherosclerosis . Less commonly, it occurs as a result of vasospasm.  

Risk factors

  • Age over 65;
  • male sex (at young and middle age men suffer from ischemic heart disease more often, the incidence becomes the same with age),
  • Cases of illness in the family;
  • Smoking;
  • Hypertension; 
  • Lipid profile: high concentration of cholesterol and low density lipoproteins;  
  • Diabetes mellitus;  
  • Sedentary lifestyle;
  • Obesity – body mass index is more than 25 kg / m2. The most dangerous is the abdominal type of obesity. A waist circumference of> 88 cm in women and> 102 cm in men may indicate it; 
  • alcohol abuse;
  • increased heart rate;
  • violations in the blood clotting system, such as increased blood clots;
  • stress.

Manifestations

At the moment, 3 types of angina are shared:

  • stable angina;
  • vasospastic (variant, Princemetal );
  • mild myocardial ischemia.

Stable angina pectoris

More often, patients can develop stable angina, which occurs in response to physical or emotional stress and can be triggered by other conditions, accompanied by rapid heartbeat and increased blood pressure.

The attack is not perceived as a clear pain, but as a difficult to achieve discomfort, which can be described as heaviness, compression, restraint, pressure or dull pain.

Retrosternal localization of pain with irradiation to the left shoulder and arm is most typical. In most cases, the pain begins inside the chest behind the sternum and from here spreads in all directions. The pain often begins behind the upper part of the sternum, than behind the lower part. Less commonly, it starts on the left near the sternum, in the epigastric region, in the left shoulder blade or the left shoulder.

Well-known is the irradiation of pain in the left shoulder blade, neck, face, jaw, teeth, as well as in the right shoulder and right shoulder blade. Described rare cases of giving pain in the left half of the waist and the left part of the abdomen, in the lower extremities.

The intensity and duration of pain varies considerably in different patients. They are not strictly dependent on the number of affected arteries of the heart and the degree of their damage. However, in the same patient with a stable course of the disease, angina attacks are quite comparable with each other, in the absence of disease progression.

The duration of an attack for angina is almost always more than one minute and usually less than 15 minutes. More often, an angina attack lasts 2–5 minutes. The attack will be shorter and less intense if the patient immediately stops the load and takes nitroglycerin. Thus, if an attack of angina is caused by physical stress, its duration and intensity to a certain extent depend on the behavior of the patient. If an attack of angina occurs in response to emotional stress, when the patient is unable to control the situation, the attack may be protracted and more intense than in response to physical exertion.

A painful attack lasting more than 15 minutes requires the intervention of a physician.

Pains at stenocardia gradually increase in the form of successive attacks of burning and compression following each other. Having reached its climax, which is always about the same in intensity for a given patient, the pain quickly disappears. The duration of the period of increase of pain always significantly exceeds the duration of the period of their disappearance.

Pains, the duration of which is calculated in seconds (less than one minute), as a rule, are of extracardiac origin. In most cases, prolonged many-hour bouts of pain, if myocardial infarction has not developed, are not associated with damage to the large coronary arteries and have a different origin.

The most important sign of stenocardia is the appearance of chest discomfort at the moment of physical exertion and the cessation of pain in 1–2 minutes after reducing the load.

If the load (fast walking, climbing stairs) does not cause chest-back discomfort, then with high probability we can assume that the patient does not have a significant lesion of the large coronary arteries of the heart.

Pain that occurs regularly after exercise or after a hard day marked by physical and emotional stress is almost never associated with ischemia of the heart. For angina pectoris is characterized by provoking a seizure in the cold or in the cold wind, which is especially often observed in the morning when leaving the house.

Angina can progress. Tolerance (tolerability) to physical exertion may decrease with time. It depends on many factors, but primarily on the patient’s adherence to treatment.

Stable angina is divided into 4 functional classes according to exercise tolerance:

  1. “Routine daily physical activity” does not cause strokes and only the symptoms described earlier appear with severe stress.
  2. “A slight limitation of physical activity”. Seizures occur when walking fast, climbing stairs, overeating, in cold weather or in windy weather.
  3. “Significant limitation of physical activity” characteristic pains occur when walking a distance of 1–2 quarters on level ground or when climbing stairs at a normal pace after 1 pass.
  4. “The inability to perform any kind of physical activity without the onset of symptoms” or angina may occur at rest.

If the patient avoids the effects of factors that provoke pain, angina attacks occur less frequently.

Sometimes there is an increase in respiration, pallor of the skin, dry mouth, increased blood pressure, heart palpitations, urge to urinate.

Vasospastic angina

A special form of angina pectoris (vasospastic or variant angina pectoris, Prinzmetal type angina pectoris ) can be detected in a number of patients . Named after the doctor, one of the first who described it as an independent form of angina in 1959. It occurs as a result of pronounced spasm of the vessel.

A particular form of angina pectoris (such as Prinzmetal ) is characterized by bouts of pain that occur at rest, accompanied by non-permanent signs of damage to the myocardial sections of the ECG.

Painless myocardial ischemia

In most cases, myocardial ischemia is asymptomatic. Quite often there are cases when a heart attack is put “in hindsight”, that is, with a planned electrocardiography, foci of necrosis are detected on the film, and upon further communication with the attending physician, it turns out that the person did not even feel any symptoms that could somehow indicate what happened

The painless form of myocardial ischemia can be detected using diagnostic methods that evaluate the work of the heart at rest, during exercise and after it.

Diagnostics

To identify angina pectoris, patient complaints are important, as it most often manifests typical symptoms. In spite of this. physicians need to make sure of their suspicions and conduct differential diagnostics with a whole list of diseases that may have similar manifestations (diseases of the pulmonary, digestive, nervous system, mental, endocrine diseases, etc.). For this purpose, laboratory research methods are used:

  • complete blood count (possible leukocytosis; decrease in hemoglobin with non-coronary causes of symptoms).
  • biochemical blood test (elevated cholesterol and LDL, low HDL, increase in glucose),
  • markers of myocardial damage ( troponin ) with an altered nature of the attacks (suspected heart attack),
  • analysis of thyroid hormones.

The instrumental method of research includes:

Invasive

  • coronary angiography (x-ray examination of vessels with a contrast agent, often combined with a surgical method for the treatment of coronary artery disease – stenting )
  • intravascular ultrasound (visualization of atherosclerotic plaques in the coronary vessels, rarely used due to the low availability of technology),
  • transesophageal electrostimulation (for the diagnosis of latent coronary insufficiency when it is impossible to use non-invasive examination methods).

These procedures are carried out only in the hospital.

Non-invasive

  • ECG (ischemic changes);
  • daily Holter monitoring;
  • ECG with physical activity (bicycle ergometry or treadmill test on a treadmill);
  • ECHO-KG (echocardiography) at rest
  • ECHO-KG with pharmacological or physical activity
  • radionuclide methods (the substance is distributed in myocardial tissue and clearly visualizes areas with insufficient blood flow)
  • MRI of the heart (with visualization problems with ECHO-KG)

Treatment of angina pectoris

The main place in the treatment of the disease is working with risk factors, mainly non-drug methods of preventing the occurrence of cardiovascular complications. First of all they include:

  • Lifestyle change;
  • Smoking cessation;

Diet for angina pectoris

  • Reducing the consumption of animal fats to 30% of the total energy value of food.
  • Reducing saturated fat intake to 30% of total fat. The consumption of cholesterol is not more than 300 mg / day .
  • Replacement of saturated fats for polyunsaturated and monounsaturated vegetable and marine origin.
  • Increased consumption of fresh fruits, plant foods, cereals.
  • Limiting the intake of total calories when overweight.
  • Reducing the consumption of salt and alcohol with high blood pressure;

Physical exercise

The increase in physical activity is given strictly individually in accordance with their tolerance to the patient. The following physical exercises are recommended: brisk walking, jogging, swimming, cycling and skiing, tennis, volleyball, dancing with aerobic exercise.

At the same time, the heart rate frequency should be no more than 60–70% of the maximum for a given age.

The duration of exercise should be 30–40 min:

  • 5–10 min. warm up
  • 20–30 min. aerobic phase
  • 5–10 min. final phase.

Regularity 4–5 p. / Week . (for longer classes – 2-3 p. / week );

With a body mass index of more than 25 kg / m, a reduction in body weight is necessary through diet and regular exercise. This leads to a decrease in blood pressure, a decrease in blood cholesterol concentration. 

Drug treatment

  • With elevated blood pressure, antihypertensive drugs are prescribed in the absence of the effect of non-drug treatment. Optimal consider blood pressure less than 140/90 mm Hg. v .;
  • In the presence of diabetes, it is necessary to take lipid – lowering drugs prescribed by an endocrinologist and strictly follow a diet.

Nitroglycerin and its analogues

Nitroglycerin – the most famous and most effective drug for the treatment of angina. When taken in a dose of 0.3–0.5 mg under the tongue, nitroglycerin clearly breaks off an attack of angina. The drug is placed under the tongue – and it resolves within one minute. The concentration of nitroglycerin in the blood reaches a maximum after 4–5 minutes and begins to decrease after 15 minutes. Reception of nitroglycerin can be repeated 2 more times.

If the attack does not subside within 10–15 minutes and after repeated administration of nitroglycerin, you need to call the ambulance and take analgesics, as a prolonged attack may be the first manifestation of myocardial infarction. Usually an attack of angina stops in 5, maximum 10 minutes.

Nitroglycerin preparations in the form of a spray have become widespread. 1 dose under the tongue corresponds to 1 tablet of nitroglycerin.

Lipid – lowering drugs

The basis of the treatment of angina, as well as all coronary heart disease – statins . They reduce the level of cholesterol, low density lipids (“bad” cholesterol) and increase the level of high density lipoproteins (“good” cholesterol). Today, atorvastatin is the most common . Taking it in high doses can not only normalize blood lipids, but also stabilize atherosclerotic plaques (stop their growth and prevent their damage, leading to thrombosis and heart attack).

Beta-blockers in the treatment of angina

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The therapeutic efficacy of beta-blockers in angina pectoris is due to their ability to lower myocardial oxygen consumption, as a result of which, despite an increase in vascular tone, a correspondence is reached between oxygen demand and its delivery to myocardial tissues.

Of beta-blockers in the hospital most widely bisporolol and metoprolol .

ACE inhibitors are indicated in patients after myocardial infarction with signs of heart failure or left ventricular dysfunction;  

Antiplatelet drugs (75 mg aspirin) are shown to all patients with a diagnosis of angina pectoris. They reduce the risk of arterial thrombosis, thereby reducing the risk of myocardial infarction.

Surgery

A large role today belongs to the surgical treatment of angina pectoris. For this, the methods of myocardial revascularization (restoration of blood flow) are used. These include:

  • coronary artery bypass surgery is a complicated operation on the heart vessels in order to bypass the site of constriction with vascular prostheses.
  • percutaneous intervention – stenting (lumen recovery vessel by posing a stent or frame within the vessel).

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