Angina pectoris is a clinical syndrome, which is mainly caused by insufficient blood supply of coronary artery, temporary myocardial ischemia and hypoxia.Common reasons areatherosclerosisCaused bycoronary artery disease 。Angina pectoris is divided into stable, unstable and variant types. The duration, inducing factors and severity of the pain caused by the decrease of coronary blood flow are different.The incidence group is mainly middle-aged and elderly people. With the increase of age, the prevalence rate of angina pectoris increases significantly.
Angina pectoris is mainly characterized by chest pain or chest discomfort, which may be compressive or burning, located at the back of the sternum, or spread to the precordial area, upper limbs, mandible, and laryngopharynx.In addition, there may be chest tightness, sweating, vomiting and other symptoms.It is worth noting that angina does not haveinfectivity。
The main method to treat angina pectoris is to improve the coronary blood supply and reduce the myocardialoxygen consumptionAnd treat coronary atherosclerosis to preventmyocardial infarctionAnd death.Patients should try to avoid inducing factors, such as physical labor and emotional fluctuations, maintain appropriate physical activity, and for unstable angina pectoris, if the drugs are ineffective, surgery can also be selected.
TCM disease name
angina pectoris
Foreign name
angina pectoris
Visiting department
Emergency Department, Chest Pain Clinic (Center), Cardiology Department
Multiple population
The incidence rate is higher among people over 45 years old, especially those between 65 and 84 years old
The main cause of angina pectoris is myocardial hypoxia due to decreased myocardial blood flow. The most common causes of myocardial blood flow reduction arecoronary artery disease 。
Pathogenesis
The lipid components in the blood deposit on the coronary artery wall, formingatherosclerosisPlaque is the main cause of angina pectoris, which leads to stenosis of arterial lumen and insufficiency of myocardial blood supply and oxygen supply.
Predisposing factors
Stable angina pectoris
Stable angina is usually caused by physical labor.When climbing stairs, exercising or walking, the heart needs more blood. When atherosclerosis narrows, the myocardium cannot get enough blood, so angina pectoris occurs.In addition to physical activity, other factors such as mood fluctuation, cold and overeating can also increase heart rate, increase myocardial oxygen consumption, and cause angina pectoris.
Unstable angina pectoris
Most have no obvious cause and can occur even at rest.A few have incentives, such as infectionhyperthyroidismEtcMyocardial oxygen consumptionIncrease, hypotension leads to decrease of coronary blood flow, anemia and hypoxemia lead to decrease of blood oxygen carrying capacity.
Variant angina pectoris
It is caused by coronary artery spasm, which is characterized by temporary narrowing of coronary artery, thus reducing the blood flow of the heart and causing chest pain.Smoking, drinking and drug abuse are important inducing factors.
symptom
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The main clinical manifestation of angina pectoris is paroxysmal pain, most of which is chest squeezing pain. It is mainly located behind the sternum and can radiate to the precordial area, upper limbs, mandible and throat. Some patients only show chest tightness.
Typical symptoms
The Canadian Cardiovascular Society (CCS) divides the severity of angina pectoris into four levels.
Level I: general physical activities (such as walking and climbing) are not limited, and angina pectoris only occurs when strong, fast or continuous force is applied.
Level II: general physical activity is slightly limited.Angina pectoris occurs within a few hours after fast walking, eating, cold, mental stimulation or waking up.Generally, it is restricted to walk more than 200m on the ground or climb more than one floor.
Grade III: general physical activity is obviously limited. Generally, angina pectoris is caused by walking within 200m on the flat ground or climbing the first floor.
Grade IV: Angina pectoris can occur during mild activity or rest.
According to different disease types, they show different disease symptoms.
Stable angina pectoris
When patients are physically active or emotionally excited, they often have oppressive, stuffy or constrictive chest pain, mainly behind the sternum, which can affect the entire precordial area, and can be accompanied by a burning sensation, which lasts for several minutes. After resting or taking nitroglycerin and other nitroester drugs under the tongue, it can be relieved within a few minutes.
Unstable angina pectoris
The location and nature of chest discomfort of the patient is similar to that of stable angina pectoris, but it is usually more severe and lasts longer, up to half an hour to one hour. Chest pain can occur in quiet or sleep, and the symptoms are not significantly relieved after rest or sublingual nitroglycerin.
Variant angina pectoris
It is mainly manifested as precordial pain in a quiet state, no activity or emotional excitement and other incentives, and may be accompanied by arrhythmia and syncope.
Accompanying symptoms
The attack may be accompanied by chest tightness, sweating, nausea, vomiting, palpitations or dyspnea.
Medical treatment
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For patients suspected of having angina pectoris, if the symptoms persist for several minutes and the pain does not disappear after rest or taking nitroglycerin under the tongue, call the emergency number immediately for help.Do not drive to the hospital by yourself unless the ambulance cannot reach.During waiting for the arrival of the ambulance, take a recumbent or semi recumbent rest.
The doctor can make a preliminary judgment on the patient's condition according to the patient's medical history, physical examination, electrocardiogram, echocardiography, CT and other relevant examinations, and formulate relevant treatment plans.
Typical attack: according to the characteristics and signs of the attack, combined with age and high-risk factors, after excluding angina caused by other reasons, the diagnosis can generally be made.Patients with no change in ECG can consider doing exercise load test.
Atypical attack: the curative effect of nitroglycerin and the change of ECG during the attack should be observed for diagnosis.If the diagnosis still cannot be confirmed, the ECG can be rechecked for many timesECG stress testOr 24-hour continuous monitoring of dynamic electrocardiogram, such as positive changes in electrocardiogram or angina pectoris induced by stress test, can also be diagnosed.
ECG is the most commonly used non-invasive examination for diagnosing myocardial ischemia. Patients whose ECG is within the normal range at rest cannot rule out myocardial ischemia. Dynamic ECG recording and (or) exercise stress test can be considered.
Also called ECG exercise load test, it is to increase the heart load through a certain amount of exercise, observe the changes of ECG and whether there is angina pectoris.The main forms of movement are the treadmill and treadmill.
Continuous dynamic monitoring of electrocardiogram
Continuous recording of the whole process of ECG activity for 24 hours or more, including ECG data under different conditions such as rest, activity, eating, work, study and sleep.
Doctors can use echocardiography to find problems related to angina, including whether the myocardial area is damaged due to long-term ischemia.
Chest X-ray
This exam takes images of the heart and lungs.This is to look for other reasons that may explain the symptoms of angina pectoris, and to check for enlarged heart and pulmonary congestion.During the inspection, the clothes and ornaments with metallic substances should be removed, and the camera should be in a static state of deep inspiration.
Radionuclide myocardial imaging and stress test
Nuclear pressure testing helps measure myocardial blood flow during rest and pressure.It is similar to a routine stress test, but during a nuclear stress test, radioactive material is injected into the blood.The part of the heart with insufficient blood supply will be shown as a perfusion defect on the image, which can determine whether there is myocardial ischemia during rest and exercise.Before the examination, adjust the usual medication according to the doctor's opinion. Avoid drinking and eating before the test, and avoid eating anything containing caffeine 24 hours before the examination.
Blood index examination
includetroponin、Myocardial enzymeBecause these indexes will change correspondingly when myocardial necrosis occurs.
Coronary artery enhanced CT
This is a non-invasive examination, mainly to determine whether the patient has coronary artery stenosis.It is mainly applicable to patients with suspicious coronary heart disease with atypical symptoms.Rest and eat normally before the examination. During the examination, the whole body may feel hot due to the injection of contrast agent into the body. Don't be nervous and panic, so as not to interfere with the examination results.Patients with normal cardiac function should drink a lot of water after examination, which is helpful to expel the contrast agent from the body.
Coronary angiography
This is an invasive examination, which can accurately reflect the extent and location of coronary artery stenosis. At present, it is the gold standard for diagnosing coronary artery disease and guiding the selection of treatment plans.After this examination, people with normal heart function should drink a lot of water to help expel the contrast agent from the body.
Intravascular ultrasound imaging
It is a new diagnostic technology combining non-invasive ultrasound technology and invasive catheter technology. This method can accurately grasp the vessel wall shape and stenosis degree, especially in the interventional diagnosis and treatment of coronary heart disease.
This is the general term for a group of mental disorders, which are mostly found in women in menopause.The main manifestation is transient stabbing pain near the precordial area, which lasts for several seconds or hours.Different from angina pectoris, the occurrence of pain has no obvious relationship with activity, and nitroglycerin has no obvious relief.
Compared with angina pectoris, myocardial ischemic necrosis is more severe and lasts longer when myocardial infarction occurs. Symptoms are not significantly relieved after sublingual administration of nitroglycerin and other nitrates.Myocardial infarction is accompanied by an increase in serum myocardial necrosis markers, but in patients with angina pectoris, this indicator does not increase significantly.
A cardiomyopathy characterized by cardiac hypertrophy.Patients with hypertrophic obstructive cardiomyopathy may have precordial pain, syncope or dyspnea, which is mostly related to activities.Different from the remission of angina pectoris patients after taking nitroglycerin, the condition of hypertrophic obstructive cardiomyopathy patients after taking nitroglycerin becomes worse, which can be identified by color Doppler echocardiography.
Aortic valve stenosis is caused by many factors. Its typical symptoms are dyspnea, angina pectoris and syncope.Compared with aortic valve stenosis, patients with simple angina had no aortic valve disease on echocardiography.
It is a kind of heart microvascular disease, which is mostly seen in women and is caused by poor capillary function of coronary artery system.Compared with typical angina pectoris, coronary angiography showed no fixed stenosis or only coronary spasm, and the prognosis was relatively good.
Cardiac hyperkinetic syndrome
It is a group of clinical syndromes caused by the overexcitation of sympathetic nerve and the increase of cardiac output.Patients often complain of palpitation, precordial discomfort, fatigue, dyspnea, anxiety and hyperhidrosis. ECG can be confused with angina pectoris, but coronary CT and coronary angiography in such patients have no obvious stenosis.
The treatment principle of stable angina pectoris is to improve the supply of coronary artery blood and reduce myocardial oxygen consumption to improve the symptoms of patients, while treating coronary atherosclerosis to prevent myocardial infarction and death.Most stable angina pectoris can be controlled by lifestyle intervention and drug treatment.
Unstable angina requires immediate relief of ischemia and prevention of serious adverse reactions such as death or myocardial infarction.If the drug is invalid, surgical treatment can be selected, including medical coronary intervention and surgical coronary artery bypass grafting. The specific operation method should follow the opinions of professional doctors.
It is mainly caused by coronary artery spasm, so the treatment is mainly to improve lifestyle and relieve spasm.
Acute treatment
When the patient suddenly feels behind the sternum or precordial area dull pain or squeezing pain, and suspects that angina pectoris has occurred, he should immediately rest, take nitroglycerin sublingually or spray nitroglycerin aerosol sublingually. If he does not feel relieved 10 minutes later, he should immediately call the emergency number.
General treatment
Stable angina pectoris
Generally, there is no need to rest in bed, and the lifestyle should be adjusted as soon as possible to avoid various inducing factors.Such as light diet, quitting smoking and limiting alcohol, adjusting workload, reducing mental burden, and maintaining proper physical activity.
Unstable angina pectoris
You should stay in bed immediately, eliminate tension and worry, and keep the environment quiet.Small doses of sedatives and anti anxiety drugs can be used to relieve angina pectoris.For patients with cyanosis, dyspnea or other high-risk manifestations, oxygen inhalation is given and blood oxygen saturation is monitored.At the same time, actively deal with the diseases that may cause the increase of myocardial oxygen consumption.
Variant angina pectoris
On the basis of quitting smoking and drinking, use drugs to relieve coronary artery spasm.Calcium channel blockers and nitrates are the main means to treat coronary artery spasm.
medication
The main effects of drug treatment include improving myocardial ischemia, alleviating symptoms, improving quality of life, and preventing acute myocardial infarction and death.
Drugs for improving myocardial ischemia and alleviating symptoms
Nitrates
NitratesDrugs can expand coronary arteries and peripheral veins, reduce myocardial oxygen consumption, increase coronary blood supply, and alleviate myocardial ischemia.Common nitrate drugs include nitroglycerin and isosorbide nitrate.When using the drug, it should be ensured that the drug is within the validity period, and try to take it while sitting to prevent postural hypotension. At the same time, attention should be paid to dizziness, headache, palpitations, hypotension and other adverse reactions.
Beta blocker
By slowing down heart rate and weakening myocardial contractility, reduce myocardial oxygen consumption, alleviate and reduce the attack of stable or unstable angina pectoris, but may aggravate or induce the attack of variant angina pectoris.Common drugs include metoprolol, bisoprolol, etc.The combined use of these drugs with nitrates is better than that of single use.Attention should be paid to monitoring blood pressure and heart rate to prevent hypotension and bradycardia.
Calcium channel blockers can effectively alleviate the symptoms of angina pectoris, and can be used as a secondary drug to treat persistent myocardial ischemia.Long acting calcium channel blockers can be taken orally in patients who still cannot control ischemic symptoms after sufficient treatment of beta blockers and nitrates.For patients with vasospasm angina pectoris, it can be used as the first choice drug.Common drugs include nifedipine, felodipine and amlodipine.For long-term use, it is recommended to use slow or controlled release preparations or long-acting preparations.
Other therapeutic drugs
yesBeta blockerOr when calcium channel blockers are contraindicated, intolerant, or unable to control symptoms, drugs such as trimetazidine, nicorandil, ivabradine hydrochloride, and ranolazine can be considered.
Trimetazidine: It can improve myocardial metabolism, improve energy utilization under myocardial hypoxia, and treat myocardial ischemia.It is mainly used for patients with stable angina pectoris, and generally not used alone.
Nicorandil: This medicine can effectively expand coronary arteries at all levels, especially coronary microvessels, alleviate coronary spasm, and improve angina symptoms.It is generally used for patients with stable angina pectoris.It should be noted that Nicorandil and phosphodiesterase 5 inhibitors (sildenafil, vardenafil, tadalafil) cannot be taken at the same time.
Drugs to prevent myocardial infarction and improve prognosis
antiplatelet drugs
Prevent thrombosis by inhibiting platelet aggregation.The commonly used drugs are aspirin, clopidogrel, tigrenol and prasugrel, and the latter three have similar mechanisms of action.
All patients with ischemic angina should take low-dose aspirin regularly every day as long as there are no contraindications.When using such drugs, it is necessary to pay attention to gastrointestinal symptoms and bleeding and other adverse reactions, and Tigrilol should also pay attention to the adverse reactions of dyspnea and bradycardia.
Drugs to reduce LDL cholesterol
Statins are the first choice of lipid-lowering drugs. In addition to reducing blood lipids, they can also further improve the function of endothelial cells, inhibit inflammation, stabilize plaque, and significantly delay the progression of lesions.Statins commonly used in clinic include simvastatin, atorvastatin, pravastatin, etc.
For patients with stable and unstable angina pectoris, statin therapy is recommended even if there is no increase in blood lipid.When statins are used, transaminase and creatine kinase should be closely monitored to prevent liver injury and muscle injury.
ACEI and ARB can significantly reduce the risk of cardiovascular death, non fatal myocardial infarction and other events in patients with coronary heart disease.
ACEI is recommended for high-risk patients with stable angina pectoris complicated with hypertension, diabetes, heart failure or left ventricular systolic dysfunction.The commonly used ACEI drugs in clinic include captopril, enalapril, perindopril, etc.Those who cannot tolerate ACEI drugs can use ARB drugs.
Beta blocker
For patients with stable angina pectoris after myocardial infarction, beta blockers may reduce the probability of reoccurrence and improve the prognosis.
surgical treatment
For patients with severe coronary artery disease and poor drug control effect, surgical treatment should be selected according to the results of coronary angiography, mainly including percutaneous coronary intervention and coronary artery bypass grafting.Middle and high-risk patients can benefit from early surgical treatment.
Percutaneous coronary intervention
Percutaneous coronary intervention is a kind of medical intervention that uses cardiac catheterization technology to dredge the narrow or even occluded coronary artery, and then improve the myocardial ischemia and hypoxia.
This operation is an important means of treating coronary heart disease, and can significantly improve the quality of life of patients.This operation can significantly reduce the incidence and mortality of myocardial infarction in high-risk patients with massive myocardial ischemia.
The operation is minimally invasive, with less trauma, high safety and quick recovery.Pay attention to smoking cessation and alcohol restriction after operation, and take medicine according to doctor's advice.
Coronary artery bypass grafting
Coronary artery bypass grafting is a kind of operation that uses its own blood vessels to bypass the stenosis of coronary artery disease, provide blood for the stenosis of coronary artery, thereby improving the blood supply and oxygen supply of myocardium, and relieving angina pectoris.
It is suitable for patients with multi vessel coronary artery disease (especially those with diabetes), complex left main coronary artery disease and patients not suitable for interventional treatment.
This operation is an open chest operation. It is highly traumatic and risky. There are many complications during and after the operation. The patient should pay attention to nutrition supplement and exercise lung function before the operation. After the operation, the patient should pay attention to expectoration in the recovery period to prevent pulmonary infection. The wound should be clean to avoid infection.
TCM treatment
With the method of "promoting blood circulation and removing stasis" (usually containingSalvia miltiorrhiza、safflower, ChuanxiongCattail, tulip, etc.), "aromatic warming" method (commonly used Suhexiang pills, Subing dropping pills, Kuanxiong pills, Baoxin pills, Shexiang Baoxin pills, etc.), and "expectorant dredging" method (Tongxinluo, etc.) are most commonly used.
prognosis
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Stable angina pectoris
The main factors determining the prognosis are the extent of myocardial blood supply and cardiac function involved by coronary lesions.Most patients can survive for many years, but there is a risk of acute myocardial infarction or sudden death.Other patients with ventricular arrhythmias or conduction block have a poor prognosis, and those with diabetes have a significantly worse prognosis than those without diabetes.
Unstable angina pectoris
The acute stage of unstable angina pectoris is generally about 2 months, during which the risk of myocardial infarction or death is the highest.After discharge, we should adhere to long-term drug treatment, control ischemic symptoms, and reduce the incidence of myocardial infarction and death.
Variant angina pectoris
If there is no obvious fixed stenosis of coronary artery, the prognosis is generally good, and patients with multi vessel or left main artery spasm have poor prognosis.
complication
Arrhythmia
Variant angina pectoris is prone to serious arrhythmia due to coronary artery spasm and sudden occlusion of blood vessels, resulting in myocardial ischemia and blood reperfusion.
miocardial infarction
Due to acute coronary artery stenosis and occlusion, blood flow interruption, myocardial necrosis will occur.
heart failure
It is also satisfied that the heart function is not complete, and the insufficiency of myocardial blood supply causes cardiac dysfunction, which cannot meet the needs of systemic organ and tissue metabolism.
prevention
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Control salt intake
Eat less salt. The main ingredients of salt aresodium chlorideLong term and large consumption of sodium chloride will increase blood pressure and damage vascular endothelium.angina pectorisThe daily intake of salt should be controlled below 6g in 30% of patients.
Control fat intake
Eat less fat and reduce calorie intake.High fat diet will increase bloodViscosity, increase blood fat,HyperlipidemiaIt is the inducement of angina pectoris.MinimizeEdible oilOil is also an important substance to form fat.But you can choose to includeUnsaturated fatty acidOfvegetable oilreplaceAnimal oilThe total daily oil consumption should be limited to 5-8 teaspoons.
