Progressive angina: classification, symptoms and treatment

Features of the disease

One of the main features of progressive angina is the rapid deterioration of the patient’s well-being and an increase in the frequency of attacks of chest pain.
The general ICD code – I20.0 – unites this disease under the general formulation of unstable angina. Depending on the moment of manifestation, this clinical symptom is divided into two groups. If squeezing and pressing pain in the chest appears during physical activity or stress (emotional stress), the disease is called angina pectoris; in their absence, angina pectoris at rest.

Important! Pain and discomfort in the absence of exercise are most dangerous.

Attacks that manifest themselves in a state of physical and emotional calm are characterized by pain intensity, duration, the presence of autonomic reactions (tachycardia, sweating, skin discoloration, nausea), severe suffocation and fear of death.

As the patient's condition worsens, progressive angina pectoris leads to the appearance of chest pain even in the absence of provoking factors. The danger of this is the high risk of heart attack: with an increase in the frequency of attacks or their duration (more than 20 minutes), the patient requires immediate diagnosis and observation in a hospital setting.

Publications in the media

Variant angina is angina characterized by the appearance of pain at rest and accompanied by a transient rise in the ST segment. This type of angina is caused by transient spasm of the coronary arteries, so it usually occurs unrelated to physical activity. Statistical data. The prevalence is unknown, but the disease appears to be quite rare.

Etiology and pathogenesis • The tone of the coronary vessels depends on the balance of vasodilator and vasoconstrictor factors. Vasodilating factors include nitric oxide (NO), the so-called endogenous relaxing factor. In the presence of atherosclerosis and hypercholesterolemia, the production of this factor by the endothelium apparently decreases, or it breaks down to a greater extent, i.e. endothelial vasodilator function decreases. This leads to an increase in the activity of vasoconstrictor agents, which contributes to the development of spasm of the coronary arteries. Severe spasm causes transmural ischemia, which is characterized by dyskinesia of the left ventricular wall, detected by echocardiography, and ST segment elevation on the ECG • Variant angina can occur with stable angina pectoris in 50% of patients. Its appearance is often noted in patients in the acute period of myocardial infarction, as well as after coronary artery bypass surgery and percutaneous transluminal coronary angioplasty.

Clinical manifestations • Typical anginal pain behind the sternum, occurring more often at night or in the early morning hours, the duration of the attack can be more than 15 minutes. Sublingual administration of nitroglycerin in most cases stops an attack of variant angina. The appearance of pain at night or early in the morning without connection with external factors is typical • At the height of pain, the appearance of ventricular arrhythmias or AV blockades is possible. Fainting due to ventricular arrhythmias or AV block may be diagnostic of variant angina • A characteristic associated symptom is migraine, which occurs in 25% of patients. In 25% of patients, variant angina is combined with Raynaud's phenomenon • The disease can occur in waves - after several attacks, a long period of remission is possible, and then resumption of attacks of variant angina.

Instrumental data • If it is possible to record an ECG during a painful attack, an elevation of the ST segment is recorded (usually in several leads at once), and its return to the baseline after relief of the pain syndrome • Daily ECG monitoring can also reveal episodes of ST segment elevation • ECG during a test with physical load provokes angina pectoris with ST segment elevation in 30% of patients in the active phase of the disease • Provocative tests: cold, test with hyperventilation, pharmacological tests with dopamine, acetylcholine. A cold test can detect an attack of angina and ECG changes in 10% of patients (place the hand up to the middle of the forearm in water at a temperature of +4 ° C for 3–5 minutes; the test is considered positive if ischemic changes appear on the ECG during immersion or over the next 10 minutes ) • Coronary angiography allows you to identify transient local spasm of the coronary artery, usually located at the site of atherosclerotic lesion (and regardless of the degree of its severity).

TREATMENT

Drug therapy • Sublingual nitroglycerin is used to relieve an attack of variant angina. In case of exacerbation of the disease (increased frequency of attacks), it is possible to use long-acting nitrates: isosorbide mononitrate is prescribed in a dose of 10-40 mg 2-4 times / day, and retard forms - 40-120 mg 1-2 times / day • Slow calcium blockers may be recommended channels - long-acting preparations of nifedipine (10–30 mg/day), verapamil (480 mg/day), diltiazem (360 mg/day). A combination of nifedipine and verapamil, nifedipine and diltiazem is possible, as well as a triple combination: long-acting nitrates + 2 slow calcium channel blockers • There has been a positive effect of using a-blockers, amiodarone, guanethidine, clonidine in case of variant angina • b-blockers can prolong an attack of variant angina, therefore, they are not indicated for this category of patients • For patients with variant angina, as with other forms of coronary artery disease, the use of acetylsalicylic acid is indicated for the prevention of MI.

Surgery. If severe atherosclerotic narrowing of the arteries is detected by coronary angiography, coronary bypass grafting or balloon dilatation is recommended. However, there is evidence that rates of operative mortality and postoperative MI in patients with variant angina are higher than in patients without variant angina.

Forecast. Spontaneous remission (disappearance of attacks) occurs quite often, sometimes lasting for years. A number of patients develop MI within 3 months. To a large extent, the prognosis of patients with variant angina is influenced by the severity of atherosclerosis of the coronary arteries.

Synonyms. Prinzmetal's angina • Vasospastic angina • Spontaneous angina.

ICD-10 • I20.8 Other forms of angina

Possible complications and prognosis

The prognosis for people with angina remains positive if the condition is corrected in a timely manner. Less than 40% of cases end in heart attack and death. But in each individual case, the prognosis corresponds to the stage and associated disorders.

Subacute, acute forms require emergency hospitalization. In the earlier stages, constant observation in the hospital and following all the cardiologist’s prescriptions are sufficient.

If treatment is not carried out or implemented incorrectly, then there is a high probability of dangerous and sometimes life-threatening complications. These include:

• arrhythmia,
• chronic heart failure,
• ischemic stroke,
• cardiac asthma,
• coronary artery thrombosis,
• swelling in the lung.

Prevention of attacks and giving up bad habits is mandatory not only for those who have experienced symptoms of progressive exertional angina. It is also important for healthy people at risk to review their lifestyle in a timely manner so as not to bring their health to disastrous consequences.

If pain in the heart and chest occurs, it is recommended to visit a doctor to diagnose the cause. This is the only way to start treatment on time and avoid complications. This is the key to positive forecasts.

Symptoms

Pain with stable angina pectoris is characterized by the following symptoms:

Retrosternal localization

As already noted, pain appears during strong emotions, physical activity, etc. In young people, pain may decrease if the load is maintained for some time or even increased.

Pain lasts 1-15 minutes

The pain is increasing. If pain lasts 15 minutes or more, the development of myocardial infarction should be assumed.

Conditions for stopping pain are stopping physical activity and taking nitroglycerin.

Irradiation of pain . The pain radiates (“gives”) to the left arm and lower jaw in most cases.

Associated symptoms are profuse sweating, nausea, vomiting, shortness of breath, fatigue, increased (sometimes decreased) blood pressure (BP), palpitations.

Physical data

During an attack of angina in a person, pale skin, sweating, immobility, increased blood pressure, and tachycardia are recorded. In some cases, a gallop rhythm and extrasystoles can be heard. An ECG detects changes in the terminal part of the ventricular complex during an attack.

Reasons for the development of the disease

The pathology progresses for a common reason - the deposition of atherosclerotic plaques on the walls of blood vessels, which leads to their narrowing and deterioration of the blood supply to the heart. Often the disease is preceded by another form - stable angina, as well as other heart pathologies, including aortic insufficiency, pulmonary hypertension and coronary spasm.

The risk group includes older patients - over 55 years old. Men suffer from the disease 20% more often than women.

There are other factors that provoke progressive angina, lead to attacks and worsening of the condition:

• Angina pectoris FC 3 is a special case of IHD. What it is

• Hypertension and a sharp increase in blood pressure;
• High cholesterol levels, increased blood viscosity;
• Stress, emotional stress and nervous strain;
• Hereditary predisposition, if one of the relatives has already suffered from the disease;
• Increased physical activity - excessive stress has a detrimental effect on the body;
• Intoxication – alcohol, tobacco, other harmful substances;
• Excess weight and poor diet, which leads to obesity;
• Diabetes.

When a patient is diagnosed with coronary artery disease, progressive angina can become a complication of this pathology. However, according to statistics, this form does not occur often if the accompanying abnormalities are treated.

Prevalence

Every year, angina pectoris is found in 0.2-0.6% of the population. These are mostly men between 55 and 64 years old. Among a population of 1 million, there are 30,000-40,000 cases per year. It is noted that the incidence depends on gender and age. Among people aged 45-54 years, angina pectoris is recorded in 2-5% of men and 0.5-1% of women, in the group of 65-74 years - in 11-20% of men and 10-14% of women (since the protective effect decreases estrogen in the postmenopausal period). Before myocardial infarction, angina pectoris is recorded in 20 out of a hundred patients, after myocardial infarction - in 50% of patients.

How is the treatment carried out?

How does angina occur? Each patient's medical history is individual, so the doctor must prescribe a treatment method. This could be medications or surgery, or folk therapy and therapeutic exercises. In all cases, you will have to change your lifestyle and review your diet.

Conservative method - drugs for angina pectoris

When the risks of complications are low, the clinical picture is generally positive, and there is no fear for the patient’s life, the doctor prescribes drug treatment. It includes taking several groups of drugs:

• Nitrates - help stop an attack and make you feel better, but are used only during exacerbations, and not on an ongoing basis;
• Beta-blockers - necessary to increase coronary lumen, reduce pain and heart rate;
• Calcium antagonists - by blocking the flow of calcium to the heart, they reduce the myocardium's need for oxygen.

Additionally, statins, antiplatelet agents, and drugs to lower blood pressure are used. It is also necessary to treat concomitant heart pathologies, because without this, the effectiveness of therapy is reduced, and taking pills may turn out to be completely useless.

Operative or surgical method

When the patient’s medical history is long, progressive angina does not subside, and the quality of life noticeably decreases, doctors resort to the surgical method, performing one of the following types of surgery:

• CABG – coronary artery bypass grafting, that is, the use of a shunt that creates an additional path for blood to bypass the problem area. The shunt can be natural (the patient's vein) or synthetic. Such treatment is painful and lengthy, in some cases, for example, with a weakened body, it is contraindicated;
• Angioplasty - a compact balloon is inserted through the femoral artery to widen the damaged area of ​​the artery. It is securely fixed and the patient is soon discharged home.

Whether it is necessary to use surgical treatment or just taking medications is enough, the doctor decides based on the tests obtained and an examination of the patient’s condition.

Therapeutic exercise and gymnastics

Another method of treating angina is moderate physical activity of the patient. The main thing is to coordinate your actions with a cardiologist. What exercises will be good for your health?

• Emergency care for angina pectoris: algorithm of actions during an attack

• Slow running or walking;
• Swimming in the pool;
• A ride on the bicycle;
• Other cardiac loads.

You should exercise daily, but in small quantities. The duration of classes is individual - for trained people, half-hour classes will be beneficial. And if you are far from sports, you need to start with small doses - training for 5-10 minutes.

Therapeutic method: lifestyle changes

Regardless of the method of treatment, the patient must understand that their usual lifestyle will have to be significantly changed. Among the mandatory measures:

• Complete cessation of smoking and drinking alcohol, since alcohol is not compatible with medications;
• Reducing physical activity is especially important for people whose work involves lifting and carrying heavy objects;
• Ensuring a calm emotional background - it is necessary to eliminate stress, anxiety, and nervous tension;
• Constant walks in the fresh air will benefit the body.

But treating angina with folk remedies without consulting a doctor is prohibited, since all kinds of decoctions, infusions and teas can be harmful to the patient. You should definitely change your diet. So, you should give up:

• Fatty meat and lard;
• Animal fats, margarines and oils;
• Egg yolk;
• Sweets, chocolate, dessert pastries and ice cream.

Eat more fruits and vegetables, eat seafood, dietary meat, greens, legumes, drink green tea. These therapeutic measures are also good for the prevention of any coronary diseases.

Classification

Today, doctors most often use the Canadian Cardiovascular Society classification of angina, which was developed in 1976.

• Functional class I - minor (everyday) physical activity does not lead to an attack of angina. Seizures occur with strong, rapid or prolonged stress at work
• Functional class II - Pain occurs when a person walks or quickly climbs stairs, when you need to go up (for example, up a slope), during emotional stress, in cold weather, after eating, when walking against the wind, for 2-4 hours after waking up. Walking on a flat surface for a maximum distance of 200 meters does not cause pain.
• Functional class III is “severe limitation of usual physical activity.” Walking on level ground or climbing one flight of stairs at a normal pace and under normal conditions provokes an attack of angina.
• Functional class IV - “impossibility of any physical activity without discomfort.” Seizures may occur at rest

Instrumental studies

Methods for objectifying the presence of IHD include:

• ECG recorded during an attack;
• daily ECG monitoring;
• stress tests - bicycle ergometry, treadmill test;
• stress echocardiography (stress echocardiography) - stress, with dobutamine, transesophageal pacing (ECS);
• coronary arteriography;
• multislice computed tomography of the coronary arteries;
• myocardial scintigraphy at rest and during physical activity.

Relative contraindications to coronary angiography:

• chronic renal failure (CRF);
• acute renal failure;
• allergy to contrast agent and iodine intolerance;
• active bleeding from the gastrointestinal tract, exacerbation of peptic ulcer;
• uncontrolled arterial hypertension;
• acute cerebrovascular accidents;
• severe coagulopathies, severe anemia;
• intoxication with cardiac glycosides;
• severe disturbance of the patient’s mental state;
• fever and acute infections;
• hypokalemia;
• severe underlying non-cardiac disease;
• infective endocarditis;
• severe damage to the peripheral arteries, limiting arterial access;
• decompensated CHF and pulmonary edema;
• patient’s refusal of possible further treatment after the study (endovascular intervention or coronary bypass surgery).