Serious question: what happens to the heart during an angina attack?

The concept of “angina pectoris” combines various types of pain symptoms in the heart area, occurring mainly during intense physical activity. In medical terms, this is a sign of myocardial ischemia, which makes itself felt in attacks for 15-20 minutes and occurs when taking nitroglycerin. Symptoms may appear simultaneously or as isolated manifestations, which complicates the initial diagnosis. When the first warning signs appear, it is important to immediately seek medical help, because angina pectoris is a sure harbinger of myocardial infarction and indicates serious disturbances in the functioning of the heart muscle.

Classification and symptoms of angina

Depending on the symptomatic picture, there are:

• a stable type of disease that occurs in an unchanged form and requires the most serious treatment;
• unstable angina - the most dangerous, of a primary nature or each time making itself felt with new symptoms;
• angina pectoris is an invariable sign of increased physical activity;
• angina at rest has no clear cause and can manifest itself even during sleep, accompanied by a feeling of panic, suffocation, and a set of autonomic disorders.

Characteristic signs allow you to distinguish angina pectoris from other diseases of the heart muscle:

• pressing burning pain;
• recoil under the left shoulder blade, in the neck or arm;
• noticeable fluctuations in pulse and blood pressure.

Any signs of angina pectoris should be a reason to contact a specialized doctor to clarify the diagnosis and prescribe appropriate treatment.

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Specifics in women

Unlike men, in women, on the contrary, the pain syndrome is more pronounced with completely satisfactory vascular patency.

I also often observe atypical symptoms of an angina attack in women, i.e. Instead of pain in the heart, the patient experiences a sharp lack of air (asthmatic form), or discomfort in the epigastric region (gastralgic version), which makes it much more difficult to recognize angina pectoris. The nature of pain in women also does not always correspond to the classic one - it can be, for example, stabbing.

Causes of angina

Long-term study of angina pectoris allows us to accurately name the physiological mechanism of the development of the disease. Due to nutritional and metabolic disorders, the lumen of the arteries gradually narrows due to atherosclerotic plaques. Deterioration of blood flow causes oxygen starvation of the heart muscle cells, which causes obvious and quite severe pain. At the same time, vascular spasm may occur, caused by nervous overstrain or hypothermia of the body.

The appearance and accumulation of atherosclerotic plaques on the walls of blood vessels is often provoked by:

• symptoms of arterial hypertension;
• smoking;
• obesity;
• symptoms of diabetes;
• physical inactivity, sedentary lifestyle;
• unsatisfactory food quality.

The process of reducing the lumen of the artery occurs gradually. When it narrows by 50% or more, the blood flow noticeably deteriorates, which leads to disturbances in the functioning of the heart muscle. Physical activity and psycho-emotional stress contribute to the aggravation of the situation, forcing the heart to work intensively against the background of oxygen starvation. Lack of oxygen causes malnutrition of muscle tissue, which causes a characteristic pain syndrome with signs of suffocation and pressure in the heart area.

Risk factors that trigger the process of vasoconstriction due to the formation of sclerotic plaques

When making a primary diagnosis, the specialist must take into account the possible effect of one or more of the following factors:

• hyperlipidemia – disorders of cholesterol metabolism with a simultaneous decrease in high-density lipoproteins;
• obesity caused by the predominance of animal fats and high-calorie foods in the diet against the background of a lack of cereals, vegetables, fruits and legumes;
• physical inactivity is a lack of movement that triggers the development of obesity due to the accumulation of cholesterol;
• arterial hypertension is a companion to coronary heart disease due to oxygen deficiency;
• anemia - a decrease in hemoglobin level against the background of general weakness of the body;
• type 2 diabetes mellitus, which is considered one of the most dangerous risk factors;
• tobacco addiction - helps to reduce the volume of oxygen in the blood, increases blood pressure and promotes spasm of arteries narrowed due to the accumulation of atherosclerotic plaques.

The action of at least two factors is sufficient for angina to become serious and require immediate intervention by a specialist.

Publications in the media

Stable angina pectoris is one of the main manifestations of coronary artery disease. The main and most typical manifestation of angina pectoris is chest pain that occurs during physical activity, emotional stress, when going out into the cold, walking against the wind, or at rest after a heavy meal.

Statistical data. Every year, angina pectoris is recorded in 0.2–0.6% of the population, with its predominance in men aged 55–64 years (0.8% of cases). It occurs in 30,000–40,000 adults per 1 million population per year, and its prevalence depends on gender and age • In the age group of the population 45–54 years, angina pectoris is observed 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 (due to a decrease in the protective effect of estrogens in menopause) • Before MI, angina pectoris is observed in 20% of patients, after MI - in 50% of patients.

Etiology • In most cases, angina pectoris occurs due to atherosclerosis of the coronary arteries. Although the correlation between the degree of atherosclerotic narrowing, its extent and the severity of the clinical manifestations of angina is insignificant, it is believed that the coronary arteries must be narrowed by at least 50–75% before a discrepancy between the myocardial oxygen demand and its delivery appears and the clinical picture of the disease arises • Other causes (relative coronary insufficiency) •• Aortic stenosis •• Hypertrophic cardiomyopathy •• Primary pulmonary arterial hypertension •• Severe arterial hypertension •• Aortic valve insufficiency.

Pathogenesis • As a result of a discrepancy (imbalance) between the myocardial need for oxygen and its delivery through the coronary arteries due to atherosclerotic narrowing of the lumen of the coronary arteries, the following occur: •• Myocardial ischemia (clinically manifested by chest pain) •• Violations of the contractile function of the corresponding part of the heart muscle •• Changes biochemical and electrical processes in the heart muscle. In the absence of a sufficient amount of oxygen, cells switch to an anaerobic type of oxidation: glucose breaks down to lactate, intracellular pH decreases and energy reserves in cardiomyocytes are depleted • Subendocardial layers are primarily affected • The function of cardiomyocyte membranes is disrupted, which leads to a decrease in the intracellular concentration of potassium ions and an increase in intracellular concentration of sodium ions • Depending on the duration of myocardial ischemia, changes can be reversible or irreversible (myocardial necrosis, i.e. infarction) • Sequences of pathological changes during myocardial ischemia: impaired myocardial relaxation (impaired diastolic function) - impaired myocardial contraction (impaired systolic function ) - ECG changes - pain syndrome.

Canadian Cardiovascular Society Classification Pain does not occur when walking or climbing stairs. Seizures occur with severe, rapid or prolonged strain at work • Class II - “mild limitation of usual activities.” Pain occurs when walking or quickly climbing stairs, walking uphill, walking or climbing stairs after eating, in the cold, against the wind, during emotional stress, or within a few hours of waking up. Walking more than 100–200 m on level ground or climbing more than 1 flight of stairs at a normal pace and under normal conditions • Class III - “significant limitation of usual physical activity.” Walking on level ground or climbing one flight of stairs at a normal pace under normal conditions provokes an attack of angina pectoris • Class IV - “impossibility of any physical activity without discomfort.” Seizures may occur at rest

CLINICAL MANIFESTATIONS

Complaints. Characteristics of the pain syndrome • Localization of pain - retrosternal • Conditions for the occurrence of pain - physical activity, strong emotions, large meals, cold, walking against the wind, smoking. Young people often have the so-called phenomenon of “going through pain” (the “warm-up” phenomenon) - a decrease or disappearance of pain while increasing or maintaining the load (due to the opening of vascular collaterals) • Duration of pain - from 1 to 15 minutes, has an increasing character (“ crescendo"). If the pain continues for more than 15 minutes, the development of MI should be assumed • Conditions for stopping pain - stopping physical activity, taking nitroglycerin • The nature of pain during angina (squeezing, pressing, bursting, etc.), as well as the fear of death, are very subjective and not have serious diagnostic significance, since they largely depend on the physical and intellectual perception of the patient • Irradiation of pain - both to the left and right parts of the chest and neck. Classic irradiation - to the left arm, lower jaw.

Associated symptoms are nausea, vomiting, increased sweating, fatigue, shortness of breath, increased heart rate, increased (sometimes decreased) blood pressure.

Angina equivalents: shortness of breath (due to impaired diastolic relaxation) and severe fatigue during exercise (due to decreased cardiac output due to impaired systolic myocardial function with insufficient oxygen supply to skeletal muscles). In any case, symptoms should decrease when exposure to the provoking factor (physical activity, hypothermia, smoking) or nitroglycerin is stopped.

Physical data • During an attack of angina pectoris - pallor of the skin, immobility (patients “freeze” in one position, since any movement increases the pain), sweating, tachycardia (less often bradycardia), increased blood pressure (less often, its decrease) • Extrasystoles, “rhythm” can be heard gallop”, systolic murmur resulting from mitral valve insufficiency as a result of dysfunction of the papillary muscles • An ECG recorded during an attack of angina can detect changes in the terminal part of the ventricular complex (T wave and ST segment), as well as cardiac arrhythmias.

Laboratory data - supporting value; They can only determine the presence of dyslipidemia, identify concomitant diseases and a number of risk factors (DM), or exclude other causes of pain (inflammatory diseases, blood diseases, thyroid diseases).

Instrumental data

• ECG during an attack of angina: repolarization disturbances in the form of changes in T waves and ST segment displacement up (subendocardial ischemia) or down from the isoline (transmural ischemia) or heart rhythm disturbances.

• Daily ECG monitoring allows you to identify the presence of painful and non-painful episodes of myocardial ischemia in the usual conditions for patients, as well as possible heart rhythm disturbances throughout the day.

• Bicycle ergometry or treadmill (stress test with simultaneous recording of ECG and blood pressure). Sensitivity - 50-80%, specificity - 80-95%. The criterion for a positive stress test during bicycle ergometry is ECG changes in the form of horizontal ST segment depression of more than 1 mm lasting more than 0.08 s. In addition, stress tests can reveal signs associated with an unfavorable prognosis for patients with angina pectoris: •• typical pain syndrome •• ST segment depression of more than 2 mm •• persistence of ST segment depression for more than 6 minutes after cessation of exercise •• appearance of segment depression ST when the heart rate (HR) is less than 120 per minute •• the presence of ST depression in several leads, ST segment elevation in all leads, with the exception of aVR •• absence of a rise in blood pressure or its decrease in response to physical activity •• the occurrence of cardiac arrhythmias ( especially ventricular tachycardia).

• EchoCG at rest allows you to determine the contractility of the myocardium and conduct a differential diagnosis of pain syndrome (heart defects, pulmonary hypertension, cardiomyopathies, pericarditis, mitral valve prolapse, left ventricular hypertrophy in arterial hypertension).

• Stress echocardiography (echocardiography assessment of the mobility of left ventricular segments with an increase in heart rate as a result of dobutamine administration, transesophageal pacemaker or under the influence of physical activity) is a more accurate method for detecting coronary artery insufficiency. Changes in local myocardial contractility precede other manifestations of ischemia (ECG changes, pain). The sensitivity of the method is 65–90%, specificity is 90–95%. Unlike bicycle ergometry, stress echocardiography can detect coronary artery insufficiency when one vessel is affected. Indications for stress echocardiography are: •• atypical angina pectoris (the presence of angina equivalents or an unclear description of the pain syndrome by the patient) •• difficulty or impossibility of performing stress tests •• uninformativeness of bicycle ergometry in a typical clinical picture of angina pectoris •• absence of changes on the ECG during stress tests due to for blocks of the His bundle branches, signs of left ventricular hypertrophy, signs of Wolff–Parkinson–White syndrome in a typical clinical picture of angina pectoris •• positive stress test during bicycle ergometry in young women (since the likelihood of coronary artery disease is low).

• Coronary angiography is the “gold standard” in the diagnosis of coronary artery disease, since it allows us to identify the presence, location and degree of narrowing of the coronary arteries. Indications (recommendations of the European Society of Cardiology; 1997): •• exertional angina pectoris above functional class III in the absence of the effect of drug therapy •• exertional angina pectoris I–II functional class after MI •• exertional angina pectoris with His bundle branch block in combination with signs of ischemia according to data myocardial scintigraphy •• severe ventricular arrhythmias •• stable angina in patients undergoing vascular surgery (aorta, femoral, carotid arteries) •• myocardial revascularization (balloon dilatation, coronary artery bypass grafting) •• clarification of the diagnosis based on clinical or professional (for example, pilots) considerations.

• Myocardial scintigraphy is a method of visualizing the myocardium that allows identifying areas of ischemia. The method is very informative when it is impossible to evaluate the ECG due to blockades of the His bundle branches.

Diagnostics. In typical cases, stable angina pectoris is diagnosed based on a detailed history, a detailed physical examination of the patient, a resting ECG recording, and subsequent critical analysis of the data obtained. It is believed that these types of examinations (history, examination, auscultation, ECG) are sufficient to diagnose angina pectoris with its classic manifestation in 75% of cases. If there is any doubt about the diagnosis, 24-hour ECG monitoring, stress tests (veloergometry, stress echocardiography) are performed consistently, and if appropriate conditions are present, myocardial scintigraphy is performed. At the final stage of diagnosis, coronary angiography is necessary.

Differential diagnosis. It should be borne in mind that chest pain syndrome can be a manifestation of a number of diseases. We should not forget that there may be several causes of chest pain at the same time • Cardiovascular disease •• MI •• Angina pectoris •• Other causes ••• possibly of ischemic origin: aortic stenosis, aortic valve insufficiency, hypertrophic cardiomyopathy, arterial hypertension, pulmonary hypertension , severe anemia ••• non-ischemic: aortic dissection, pericarditis, mitral valve prolapse • Gastrointestinal diseases •• Esophageal diseases - esophageal spasm, esophageal reflux, esophageal rupture •• Stomach diseases - peptic ulcer • Diseases of the chest wall and spine •• Anterior thoracic syndrome walls •• Syndrome of the anterior scalene muscle •• Costal chondritis (Tietze syndrome) •• Damage to the ribs •• Herpes zoster • Lung diseases •• Pneumothorax •• Pneumonia involving the pleura •• PE with or without pulmonary infarction • Pleural diseases.

TREATMENT. The goals are to improve the prognosis (prevention of MI and sudden cardiac death) and reduce the severity (elimination) of symptoms of the disease. Non-drug, medicinal (drug) and surgical treatment methods are used.

• Non-drug treatment - impact on risk factors for coronary artery disease: dietary measures to reduce dyslipidemia and reduce body weight, smoking cessation, sufficient physical activity in the absence of contraindications. Normalization of blood pressure levels and correction of carbohydrate metabolism disorders are also necessary.

• Drug therapy - three main groups of drugs are used: nitrates, b-blockers and slow calcium channel blockers. Additionally, antiplatelet agents are prescribed.

Nitrates. When nitrates are administered, systemic venodilation occurs, leading to a decrease in blood flow to the heart (reduction in preload), a decrease in pressure in the chambers of the heart and a decrease in myocardial tension. Nitrates also cause a decrease in blood pressure, reduce resistance to blood flow and afterload. In addition, the expansion of large coronary arteries and an increase in collateral blood flow are important. This group of drugs is divided into short-acting nitrates (nitroglycerin) and long-acting nitrates (isosorbide dinitrate and isosorbide mononitrate).

• To relieve an attack of angina, nitroglycerin is used (tablet forms sublingually in a dose of 0.3–0.6 mg and aerosol forms - spray - are also used in a dose of 0.4 mg sublingually). Short-acting nitrates relieve pain in 1–5 minutes. Repeated doses of nitroglycerin to relieve an attack of angina can be used at 5-minute intervals. Nitroglycerin in tablets for sublingual use loses its activity after 2 months from the moment the tube is opened due to the volatility of nitroglycerin, so regular replacement of the drug is necessary.

• To prevent angina attacks that occur more often than once a week, long-acting nitrates are used (isosorbide dinitrate and isosorbide mononitrate) • Isosorbide dinitrate at a dose of 10-20 mg 2-4 times a day (sometimes up to 6) 30-40 minutes before expected physical activity. Retard forms of isosorbide dinitrate - at a dose of 40-120 mg 1-2 times / day before the expected physical activity • Isosorbide mononitrate at a dose of 10-40 mg 2-4 times / day, and retard forms - at a dose of 40-120 mg 1-2 r/day also 30–40 minutes before the expected physical activity.

• Tolerance to nitrates (loss of sensitivity, addiction). Regular daily use of nitrates for 1–2 weeks or more can lead to a decrease or disappearance of the antianginal effect •• The reason is a decrease in the formation of nitric oxide, acceleration of its inactivation due to increased activity of phosphodiesterases and increased formation of endothelin-1, which has a vasoconstrictor effect •• Prevention - asymmetric (eccentric) administration of nitrates (for example, 8 a.m. and 3 p.m. for isosorbide dinitrate or only 8 a.m. for isosorbide mononitrate). In this way, a nitrate-free period lasting more than 6–8 hours is provided to restore the sensitivity of the SMC of the vascular wall to the action of nitrates. As a rule, a nitrate-free period is recommended for patients during periods of minimal physical activity and a minimal number of painful attacks (individually in each case) •• Other methods of preventing nitrate tolerance include the use of sulfhydryl group donors (acetylcysteine, methionine), ACE inhibitors (captopril, etc. ), angiotensin II receptor blockers, diuretics, hydralazine, however, the incidence of tolerance to nitrates with their use decreases to a small extent.

Molsidomine is similar in action to nitrates (a nitrocontaining vasodilator). After absorption, molsidomine is converted into an active substance that is converted into nitric oxide, which ultimately leads to relaxation of vascular smooth muscle. Molsidomine is used in a dose of 2–4 mg 2–3 times/day or 8 mg 1–2 times/day (long-acting forms).

b-Adrenergic blockers. The antianginal effect is due to a decrease in myocardial oxygen demand due to a decrease in heart rate and a decrease in myocardial contractility. For the treatment of angina pectoris the following is used:

• non-selective b-adrenergic blockers (act on b1- and b2-adrenergic receptors) - for the treatment of angina, propranolol is used in a dose of 10-40 mg 4 times / day, nadolol in a dose of 20-160 mg 1 time / day;

• cardioselective b-adrenergic blockers (act primarily on b1-adrenergic receptors of the heart) - atenolol at a dose of 25–200 mg/day, metoprolol 25–200 mg/day (in 2 doses), betaxolol (10–20 mg/day), bisoprolol ( 5–20 mg/day).

• Recently, b-blockers have been used that cause peripheral vasodilation, such as carvedilol.

Slow calcium channel blockers. The antianginal effect consists of moderate vasodilation (including coronary arteries), reducing myocardial oxygen demand (in representatives of the verapamil and diltiazem subgroups). Used: verapamil - 80-120 mg 2-3 times / day, diltiazem - 30-90 mg 2-3 times / day.

Prevention of MI and sudden cardiac death

• Clinical studies have shown that the use of acetylsalicylic acid at a dose of 75–325 mg/day significantly reduces the risk of developing MI and sudden cardiac death. Patients with angina pectoris should be prescribed acetylsalicylic acid in the absence of contraindications - peptic ulcer, liver disease, increased bleeding, intolerance to the drug.

• The prognosis of patients with stable angina pectoris is also positively influenced by reducing the concentration of total cholesterol and LDL cholesterol using lipid-lowering drugs (simvastatin, pravastatin). Currently, optimal levels are considered to be no more than 5 mmol/l (190 mg%) for total cholesterol and no more than 3 mmol/l (115 mg%) for LDL cholesterol.

Surgery. When determining the tactics of surgical treatment of stable angina pectoris, it is necessary to take into account a number of factors: the number of affected coronary arteries, left ventricular ejection fraction, and the presence of concomitant diabetes. Thus, with one or two vessel lesions with a normal left ventricular ejection fraction, myocardial revascularization is usually started with percutaneous transluminal coronary angioplasty and stenting. In the presence of two or three-vessel disease and a decrease in the left ventricular ejection fraction of less than 45% or the presence of concomitant diabetes, it is more advisable to perform coronary artery bypass grafting (see also Atherosclerosis of the coronary arteries).

• Percutaneous angioplasty (balloon dilatation) - expansion of a section of the coronary artery narrowed by an atherosclerotic process with a miniature balloon under high pressure under visual control during angiography. The success of the procedure is achieved in 95% of cases. Complications are possible during angioplasty: •• mortality is 0.2% with single-vessel disease and 0.5% with multi-vessel disease, MI occurs in 1% of cases, the need for coronary artery bypass grafting appears in 1% of cases; •• late complications include restenosis (in 35–40% of patients within 6 months after dilatation), as well as the appearance of angina (in 25% of patients within 6–12 months).

• In parallel with the expansion of the lumen of the coronary artery, stenting has recently been used - implantation of stents (thin wire frames that prevent restenosis) at the site of narrowing.

• Coronary artery bypass grafting is the creation of an anastomosis between the aorta (or internal mammary artery) and the coronary artery below (distal) the site of narrowing to restore effective blood supply to the myocardium. A section of the saphenous vein of the thigh, the left and right internal mammary arteries, the right gastroepiploic artery, and the inferior epigastric artery are used as a graft. Indications for coronary artery bypass grafting (recommendations of the European Society of Cardiology; 1997) •• Left ventricular ejection fraction less than 30% •• Lesion of the trunk of the left coronary artery •• The only unaffected coronary artery •• Left ventricular dysfunction in combination with three-vessel disease, especially with damage to the anterior interventricular branches of the left coronary artery in the proximal part •• When performing coronary bypass surgery, complications are also possible - MI in 4-5% of cases (up to 10%). Mortality is 1% for single-vessel disease and 4–5% for multi-vessel disease. Late complications of coronary artery bypass grafting include restenosis (with the use of vein grafts in 10–20% of cases during the first year and 2% each year for 5–7 years). When arterial grafts are used, shunts remain open in 90% of patients for 10 years. Within 3 years, angina returns in 25% of patients.

The prognosis for stable angina pectoris with adequate treatment and monitoring of patients is relatively favorable: mortality is 2–3% per year, fatal MI develops in 2–3% of patients. A less favorable prognosis is for patients with a decrease in the ejection fraction of the left ventricle, a high functional class of stable angina pectoris, elderly patients, patients with multivessel disease of the coronary arteries, stenosis of the main trunk of the left coronary artery, proximal stenosis of the anterior interventricular branch of the left coronary artery.

Age characteristics • Children. The most common cause of symptoms of angina pectoris in children is hereditary dyslipidemia • Elderly - high sensitivity to the side effects of drugs (for example, severe depression when prescribing b-blockers) • Pregnancy - after clarifying the diagnosis, careful observation by an obstetrician and cardiologist is necessary, an increase in the need for oxygen during pregnancy increases the symptoms of angina pectoris.

Prevention • Stop smoking, diet low in cholesterol and fat, regularly perform a set of special exercises • Lipid-lowering drugs.

Synonyms • Angina pectoris • Angina pectoris • Heberden's disease.

ICD-10 • I20.8 Other forms of angina

Methods for diagnosing angina pectoris

Laboratory and instrumental examination methods help to give the patient an accurate diagnosis. A blood test can determine:

• the level of total cholesterol and so-called lipid fractions;
• blood clotting indicators;
• glucose level;
• markers of systemic inflammation;
• the presence in the blood of other substances that affect cholesterol metabolism and the level of oxygen saturation in the blood.

Among the instrumental diagnostic methods, the following are of particular importance:

• ECG at the peak of an angina attack;
• daily ECG monitoring, which allows to identify abnormalities in the functioning of the heart in various external conditions;
• EchoCG – reveals ischemic changes and disturbances in the process of contraction of the heart muscle;
• bicycle ergometry - identifies the maximum level of load for the patient without the risk of symptoms of angina pectoris;
• stress echocardiography using ultrasound waves;
• computed tomography of the heart structure;
• coronary angiography - radiography with the introduction of a contrast agent.

Based on the results obtained, a treatment course is developed and a decision is made on surgical intervention.

Pathogenesis

A loss of blood supply to the heart muscles, called ischemia, often occurs due to damage to the coronary arteries leading from the heart. They reduce their permeability, leading to a decrease in the volume of incoming blood.

Angina usually occurs after the arteries are 75% blocked. This can be triggered by a variety of factors, including physical activity and stress.

Also, for the normal functioning of the heart, a constant flow of blood is necessary to the coronary arteries, which supply blood to the myocardium. Diseases of the esophagus, some parts of the spine, and the gallbladder can worsen the patient’s condition, as they provoke reflex impulses and arrhythmia.

Treatment of angina

Since stenography develops against the background of coronary heart disease, it is important to eliminate the root cause of the disease in order to then cope with associated symptoms. At the same time, measures are taken to relieve pain and prevent new attacks.

First aid for angina pectoris is to take nitroglycerin, which reduces pain. A permanent treatment course focuses on taking anti-ischemic drugs, thanks to which the heart continues to work stably in conditions of lack of oxygen. Stenting and coronary artery bypass surgery allow the lumen of blood vessels to expand, restoring the conductive capacity of the arteries. Other clinical recommendations for angina pectoris are selected taking into account the patient’s condition, his age and the severity of cardiac pathology.

Features in men

Males are characterized by the so-called typical clinical picture of angina (burning/pressing pain behind the sternum, developing after physical work). However, pain often makes itself felt too late, and its intensity does not correspond to the degree of damage to the coronary arteries. Those. slight discomfort in men occurs against the background of a pronounced decrease in the lumen of blood vessels.

In other words, the appearance of angina in a man indicates advanced atherosclerosis.

I constantly have to diagnose IHD in men only when they are admitted to the cardiac intensive care unit with myocardial infarction.

FAQ

Why is angina pectoris dangerous?

If the patient neglects his health and refuses medical care, the frequency of attacks may increase and the pain may intensify. A further decrease in the lumen can cause acute oxygen starvation and the development of myocardial infarction with a poor prognosis.

How to relieve an angina attack at home?

When the first sensations of pain appear, you should immediately stop working or moving, take a sitting or lying position, put a nitroglycerin tablet under your tongue, which should always be at hand. If your eyes darken and perception deteriorates, you should ask others for help. It is important to try to record the condition preceding the attack and the duration of the last one in order to report it to the attending physician.

How to determine angina?

Among the characteristic signs of angina pectoris are severe pressing pain in the heart area with a return to the peripheral parts of the body, noticeable fluctuations in pulse and pressure. The attack occurs with sudden physical or psycho-emotional stress and subsides within 15-20 minutes. Only the attending physician can carry out differentiated diagnostics and accurately name the cause of the disease.

First aid for an angina attack

If an angina attack occurs, you must follow the instructions received from your attending physician or (if there were no such instructions) follow the algorithm:

1. Note the time of onset of the attack.
2. Measure blood pressure, heart rate and pulse.
3. Sit (preferably in a chair with armrests) or lie in bed with the head of the bed raised.
4. Provide fresh air (free your neck, open a window).
5. Take acetylsalicylic acid (aspirin 0.25 g), chew the tablet and swallow.

You should not take acetylsalicylic acid (aspirin) if you are intolerant to it (allergic reactions) and have already taken it that day, as well as if there is a clear exacerbation of gastric and duodenal ulcers.

6. Take 0.5 mg of nitroglycerin. If in the form of a tablet, put it under the tongue and dissolve; if in the form of a capsule, bite it, do not swallow; if in the form of a spray, inhale (inject) one dose under the tongue without inhaling.

If, after taking nitroglycerin, severe weakness, sweating, shortness of breath, or a severe headache appears, then you need to lie down, raise your legs (on a bolster, pillow, etc.), drink one glass of water and then do not take nitroglycerin.

You should not take nitroglycerin if you have low blood pressure, severe weakness, sweating, severe headache, dizziness, acute impairment of vision, speech or coordination of movements.

7. If the pain has completely disappeared and the condition has improved after taking aspirin and 1 dose of nitroglycerin after 5 minutes, limit physical activity and discuss further treatment with your doctor.

8. If the pain persists for more than 10-15 minutes, you must take nitroglycerin a second time and urgently call an ambulance!

ATTENTION ! If aspirin or nitroglycerin is not available and the pain persists for more than 5 minutes, call an ambulance immediately!

9. If pain persists even after taking the second dose of nitroglycerin after 10 minutes, you need to take nitroglycerin a third time. Wait for an ambulance.

Rules for taking nitroglycerin

As part of first aid for an angina attack, you can use both tablets (to relieve an attack outside the home) and drops. The medicine is dropped onto a piece of sugar, which is placed under the tongue and wait until it dissolves. Check the dosage with your doctor, but remember: you cannot take more than 3 tablets (drops) in 15 minutes.

You may feel dizzy, because the effect of the medicine is to dilate blood vessels and reduce pressure. Therefore, before taking, take a comfortable position, sitting or lying down.

What can the disease be confused with?

As for diseases not related to the cardiovascular system, based on the symptoms and signs, angina pectoris can be mistaken for:

• osteochondrosis of the cervical or thoracic spine;
• vegetative-vascular dystonia;
• gastrointestinal diseases (diaphragmatic hiatal hernia);
• pleurisy, pulmonary embolism;
• pinched nerves.

Usually this disease is confused with the onset of myocardial infarction. The signs are really very similar. The main difference is that an attack of angina is relieved by taking nitroglycerin. In case of a heart attack, the medicine does not work or relieves pain only slightly and temporarily.

Which doctor should I contact?

Any alarming signs characterizing pathological processes in the heart are a reason to immediately go to an appointment with a cardiologist. Self-medication, the use of traditional methods or advice from doctors that other patients have received is unacceptable. Each clinical case of angina is unique - it is provoked by various factors and has varying degrees of severity, therefore, without individual diagnosis and a treatment program developed specifically for you, it will not be possible to overcome the disease.

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How and with what they are treated

Angina pectoris requires competent and comprehensive treatment, including the use of medications, surgical interventions, and lifestyle correction.

I treat angina pectoris using the following medications:

• beta-blockers (Bisoprolol, Metoprolol) – reduce the myocardial oxygen demand and improve its blood circulation;
• calcium channel blockers (Diltiazem, Verapamil) - have a similar mechanism of action. I resort to them in case of contraindications to beta blockers (for example, with severe bronchial asthma);
• antiplatelet agents (Acetylsalicylic acid, Clopidogrel) – prevent the “gluing” of platelets, thereby preventing the formation of blood clots;
• anticoagulants (unfractionated, low molecular weight heparin) – also suppress the process of blood clot formation by affecting plasma coagulation factors;

• statins (Atorvastatin, Rosuvastatin) - help slow down the growth of atherosclerotic plaques by lowering cholesterol levels in the blood;
• nitrates (Nitroglycerin, Isosorbide dinitrate) and dihydropyridine calcium channel blockers (Amlodipine, Nifedipine) - cause dilation of the coronary arteries, which increases blood flow to the myocardium;

An important point is that nitrate tablets should not be swallowed, but placed under the tongue.

In the hospital

It is almost always worth starting treatment for angina in a hospital, especially for unstable forms. When a person is admitted to the hospital, I use the following drug therapy regimens depending on the type of angina:

1. Stable – beta-blocker, antiplatelet agent, statin. Nitrates only during an attack, taking into account that the break between doses should be at least 10-12 hours. With more frequent use, the effectiveness of nitrates decreases several times.
2. Unstable - beta-blocker, necessarily 2 antiplatelet drugs, an anticoagulant, a narcotic painkiller, a statin.
3. Vasospastic - dihydropyridine calcium channel blocker, nitrate, antiplatelet agent.

Cardiac syndrome X deserves special attention. Standard therapy is effective in only half of patients with this diagnosis. To the treatment of these patients, it is necessary to add antidepressants, sedatives, hormone replacement therapy with estrogen, and aminophylline. Psychotherapy can also help.

If a patient with stable or unstable angina has severe atherosclerotic damage to the coronary vessels, as well as a high cardiovascular risk (old age, diabetes mellitus, rapid progression of the disease, increased cholesterol and blood pressure, etc.), surgical treatment is indicated for him. .

There are two types of operations:

• coronary artery bypass grafting (CABG);
• percutaneous transluminal balloon coronary angioplasty (PTCA), or stenting.

With CABG, a fistula (shunt) is created between the internal mammary and coronary arteries. This method is used in cases of multiple damage to the heart vessels by atherosclerosis.

During PTCA, a metal stent (a spring-shaped frame) is inserted into the artery, which widens the lumen of the vessel. Drug coatings are sometimes used. The rationale for choosing PTCA is a hemodynamically significant decrease in patency (less than 50%) in one artery. Often, stenting is performed in parallel with coronary angiography.

Degree of disease development

Angina can be stable or unstable. The first category is divided into:

1st degree

– difficult to diagnose, manifests itself only during prolonged physical exertion.

2nd degree

– climbing stairs is very difficult; in the slightest stressful situation, tachycardia and a pressing sensation in the chest occur. In a state of physical or emotional peace, the discomfort goes away.

3rd degree

– even minor stress causes an attack; it can also be triggered by changes in the weather.

4th degree

– an extremely dangerous stage of angina pectoris for humans. Elementary loads and any excitement are contraindicated. Attacks can occur even when a person is resting and not at all nervous.

Unstable angina is divided into:

• Occurring for the first time
  is a serious reason to suspect cardiac ischemia in the patient.
• Progressive
  – the condition gradually worsens, attacks become more frequent and intensified.
• Post-infarction
  – angina develops for the first time after a heart attack or surgery.
• Spontaneous (angina at rest)
  - occurs unexpectedly without obvious reasons.

Where can I get diagnosed and treated?

Rest assured that your heart is not in danger! If the first symptoms and signs of angina appear, consult a qualified healthcare provider. Cardiologists at the CBCP Center for Circulatory Pathology are ready to help you. The clinic will offer professional consultation and modern types of diagnostics, through which the doctor will receive objective, detailed and accurate information about the disease.

If you discover serious violations, do not despair! The level of medicine at CBCP makes it possible to effectively treat complex cardiovascular diseases using medicinal and non-surgical methods.