Unstable angina - Causes, Symptoms and Treatment .MF .
reasons for unstable angina
Treatment of unstable stenokrdii
Forecast To understand what is unstable angina, what she called, and the consequences, it is necessary to dwell briefly on the features of blood supply to the heart.
For a good performance of the heart muscle it requires a sufficient quantity of glucose and oxygen.These substances are delivered with arterial blood by the coronary (coronal) arteries originating from the aorta.There are right and left artery, the latter is divided into anterior descending and circumflex branch.When physical or emotional stress when increasing the heart rate, myocardial oxygen demand increases, which must be accompanied by an adequate increase in coronary blood flow.
If the coronary arteries spasmatic (compressed) or sealed inside a thrombus and / or atherosclerotic plaque, myocardial perfusion mismatch develops its oxygen demand.Myocardial ischemia occurs - a chain of pathological processes in the
Angina - a clinical syndrome that develops in patients with coronary heart disease, is characterized by the occurrence of myocardial ischemia during exercise or at rest, and is manifested attacks of crushing, burning pain in the heart, disappearing when taking nitroglycerin.
Angina is classified into stable and unstable .angina attacks flow stability is determined character (duration, intensity, frequency of pain), as well as the efficiency of nitroglycerin for the treatment of pain.This separation is important in terms of prognosis, as the likelihood of myocardial infarction and its complications is several times higher in unstable form of angina.Also depends on the tactics of the patient's conduct, because doctors gospitaliziruya patients with unstable angina, already prepared for the fact that the high risk of heart attack.Accordingly, intensive therapy will aim to prevent further complete coverage of the coronary arteries, while in a stable form rather outpatient care and timely to prescribed drugs.
Stable angina is divided into four functional classes defined depending on the physical activity that the patient can move without pain in my heart.
Unstable angina is a kind of "aggravation" of coronary disease when under the influence of certain reasons is an increase in the frequency, duration and intensity of the attacks of cardiac pain with lower tolerability loads than it was before.Unstable form includes the following types of angina:
- first emerged angina,
- Prinzmetal angina,
- post-infarction angina,
- progressive angina.
Unstable angina may lead to the development of a myocardial infarction, or go into the category of stable angina may have a higher functional class than the patient had before, that is, with a decrease in exercise tolerance.Often doctors during a conversation with the patient used the expression "PIS", characterizing the diagnosis of unstable angina that is not entirely justified, since it is not in all cases it will be the final development of myocardial infarction.
reasons for unstable angina
main cause of angina is the deposition of atherosclerotic plaques in the lumen of the coronary arteries, thereby reducing the amount of blood bringing oxygen the heart muscle.Clinically, this process begins to show the narrowing of the arterial lumen by more than 50%.By atherosclerosis risk factors include obesity, lipid (fat) metabolism and cholesterol metabolism, hypertension, diabetes, nicotine addiction, age over 45 years.
As further growth occurs it atherosclerotic plaque destabilization, i.e. capsules rupture plaques settling on the surface of platelets and thrombus formation, even more overlapping lumen.As a result, destabilization of the plaque, which is exacerbated by spasm of the affected vessel, blood flow to the myocardium is reduced, which is clinically manifested in increased frequency of pain attacks the heart and can lead to myocardial infarction.This is the reason for the progression of coronary artery disease and the occurrence of unstable angina.
The figure shows that the formation of a blood clot on the surface of the plaque leads to complete occlusion (blockage) of the coronary artery.
factors causing the development of unstable angina may be the excessive exercise, strong emotional stress, worsening of hypertension, alcohol abuse, cardiac decompensation (chronic heart failure, hypertrophic cardiomyopathy, valvular heart disease) and some extracardiac diseases (hyperthyroidism, anemia,diabetes).
symptoms of unstable angina
With the development of unstable angina patient complained of pain in the heart - pressing, burning, squeezing, or pain in the chest on the left side of the chest, which can be given in the left arm, shoulder, jaw, the left side of the neck.Sometimes the pain can be more local in nature, without irradiation, for example, be just between the shoulder blades, or may take on the character encircling pain.In some cases, abdominal form of myocardial infarction may result from unstable angina, which is manifested by pain in the abdomen only.In attacks the patient's pain can disturb the fear of death, feeling short of breath, dizziness, sweating.
main criteria for unstable angina are the following symptoms:
- pain occur frequently,
- attacks become stronger in intensity,
- attacks last longer in length, about 10 to 15 minutes or longer,
- attacks can occur both in the performance of smallerthe amount of physical activity than before, and at rest,
- nitroglycerin under the tongue remains without effect or bring short-term relief, the need for taking nitroglycerin increases.
With the development of new-onset and progressive angina these complaints concerned the patient during the last month, and in post-infarction angina - from two days to eight weeks after a heart attack.
Angina Printsmetalla (variant, vasospastic angina) refers to unstable angina due to the fact that its occurrence is prognostically unfavorable, and is fraught with high risk of developing myocardial infarction macrofocal the first two - three months from the occurrence of the first attack.It is characterized by the occurrence of complaints of pain in the heart of most young men at rest, often in the early morning hours (probably due to the effect of changes in the autonomic nervous system on the heart at night, especially with the increasing influence of the vagus nerve).Between bouts of pain, patients are able to perform significant physical activity.Depletion of perfusion of the heart muscle at the same time as associated with unstable angina, coronary spasm, but not necessarily, the patient may be coronary atherosclerosis.
diagnosis of unstable angina
Besides questioning and examination of the patient, in which assessed the complaint, the general condition, hemodynamic stability (rhythm, frequency and strength of heart rate, blood pressure - low or high), obligatory in standard ECG recording.ECG - criteria for unstable angina are depression (reduction) or elevation (ascent) segment ST, high coronary T wave, negative T waves, as well as the combination of these features in different leads.These signs of ischemia can occur only under load or at rest, and may be absent altogether.
signs of myocardial ischemia on ECG - segment depression ST (left) and negative T waves in the chest leads (right).
To decide on hospitalization of the patient in the emergency order enough of the front desk at the hospital once the ECG.
in cardiology hospital examination to be completed by the following diagnostic methods:
- CBC - may increase white blood cells (leukocytosis).
- biochemical analysis of blood - increased cholesterol levels and changes in the composition of its factions, changes the activity of enzymes LDH, AST, creatine kinase (CK), troponin T (a marker of damage to the heart muscle).troponin levels increase in myocardial infarction.
- daily monitoring of ECG Holter detect episodes of myocardial ischemia, including painless, communicates pain attacks with physical activity due to the diary, which leads the patient in the study day.
- echocardiography (ultrasound of the heart) - reveals hypo zone - and akinesia (lack or loss of myocardial sites), may be a violation of left ventricular systolic function, reduced stroke volume and ejection fraction.
- radionuclide diagnostic methods (myocardial perfusion scintigraphy) is informative for non-compliance of clinical laboratory and ECG data - the criteria to distinguish necrosis of myocardial ischemia (heart attack from angina).
- coronary angiography (CAG) is conducted to the "inside" to see and assess the patency of the coronary vessels, as well as decide whether coronary stenting.
Despite the fact that sometimes it is that the patient presents the above symptoms and EKG - ischemic symptoms or myocardial necrosis not, the patient still has to be hospitalized in the cardiology hospital (if the requirements of pain treated by a physician as angina, heart, and not aspain of intercostal neuralgia, gastritis, pancreatitis, for example).The need for hospitalization due to the fact that sometimes the symptoms with the ECG of myocardial damage may be delayed for some time, up to two days, even if the patient is already taking place the development of myocardial infarction.
Therefore, when deciding on the admission and appointment of intensive treatment of patients with symptoms of unstable angina should rely not only on a set of clinical and ECG - the criteria, but also on each of them separately.
Treatment of unstable angina
patient must remember that if he for the first time there were pains in the heart or was more frequent and increased pain with existing angina, he should see a doctor, because only a doctor can conduct a full examinationand decide on the need for hospitalization.
With the sudden appearance of intense, do not respond to pain by nitroglycerine in the heart, the patient should immediately call an ambulance.
Treatment of unstable angina must be conducted in the cardiology or therapeutic hospital, while general grave condition of the patient - in the ICU.
Prehospital, alone or as directed the doctor ambulance, the patient should take 1 - 2 tablets of nitroglycerin or 1 - 2 doses nitrospreya under the tongue, followed by 300 mg of aspirin (three tablets) sucked in the mouth to prevent blood further thickening andblood clots in the coronary vessels.
General measures in the treatment of unstable stenokrdii:
- appointed bed mode or polupostelny limited physical activity,
- diet should be gentle, eating frequent and small meals (5 - 6 times a day).
Drug therapy reduces the appointment of the following groups of products:
- nitrates intravenously slowly - nitroglycerin or isosorbide dinitrate first two days drips continuously, then gradually canceled,
- heparin IV bolus dose of 5,000 units, followed by subcutaneous 5000 IU four timesper day under the control of blood coagulation indexes (APTT every two - three days),
- usual dose aspirin (100 - 200 mg per day).To eliminate the effects on the gastric mucosa used drugs with enteric coating or capsule - Aspirin Cardio, Cardiomagnyl, tromboAss, aspikor etc.
-. Beta - blockers - carvedilol, propranolol, etc. are contraindicated in bronchial asthma, chronic obstructive pulmonary disease, as well.Printsmetalla angina with angiographic coronary vessels intact (with no signs of destruction of atherosclerosis).With this type of angina appointed calcium channel antagonists - verapamil, nifedipine, Corinfar, kordafen.The last three of the drug in cases of "pure" vasospastic angina may have a greater effect for pain relief attacks than nitroglycerin.When coronary atherosclerosis nifedipine is not shown, as it causes an increase in heart rate
- ACE inhibitor - perindopril, captopril, prestarium, noliprel,
- diuretics are appointed with symptoms of congestive heart failure in cardiac asthma and pulmonary edema - furosemide, or Lasix intravenously, with the initialsigns of stagnation - indapamide daily,
- while maintaining the pain can be assigned leptoanalgesia, used in the treatment of myocardial infarction - the use of neuroleptics (droperidol) and narcotic analgesics (Promedolum or fentanyl).
With the development of complications (myocardial infarction, pulmonary edema, cardiac arrhythmias, thromboembolic events) held posindromnaya therapy in coronary care unit.
Assigned coronary angiography for diagnostic purposes can be extended to medical operations conducting emergency balloon angioplasty or coronary stenting.Also from the surgical treatment can be shown to aorto - coronary bypass surgery.Indications and contraindications for operations strictly determined individually in each case.
Lifestyle unstable angina
For patients who have had unstable angina, after discharge from the hospital or nursing home (where the patient may be sent to your doctor directly from hospital) lifestyle should be subject to general recommendations, the designated hospital - the restrictive regime and a light dietwith a regular intake of prescribed drugs.The concept of limiting the exclusion regime includes significant physical and psycho-emotional stress, compliance with work and rest (when stored operation and no disability), the organization of their daily routine given enough time to sleep and rest, prolonged exposure to the outdoors.
excluded salty, spicy, fatty, fried, smoked food, alcohol, limited to fatty fish and meat, animal fats, encouraged the consumption of vegetables, fruits, juices, jellies, compotes, milk, cereals in the diet.The finished product can be steam, boiled, baked form.The diet should conform to the principles of proper nutrition and be aimed at the fight against excess weight.
require lifelong continuous administration of drugs prescribed by your doctor, with the correction of the treatment schemes, if necessary to prevent repeated attacks of severe pain in the heart and of heart attack and other complications.
recovery performance with uncomplicated unstable angina possible within 10 - 14 days of hospitalization and the start of treatment, with follow-up care in the sanatorium temporary disability is extended to 24 days, in complicated question can be put on the examination of permanent incapacity (disability) medicalCommission polyclinics (ITU - medical - social examination).Complications of the disease
Complications include unstable angina, myocardial infarction, congestive heart failure, including pulmonary edema, arrhythmias, ventricular fibrillation and sudden cardiac death.