Angina: types, symptoms, first aid and treatment

Scientific editor: Strokina OATherapist, doctor of functional diagnostics.
July 2019.

Synonyms: angina pectoris, angina pectoris

ICD-10 code: I20

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Angina - the most common form of coronary heart disease. Stable angina is manifested discomfort or dull pain in the chest after exercise or high stress. Duration of seizures is less than 15 minutes and removed nitroglycerin. The basis of the therapy dose up exercise and diet. Also used statins, cholesterol-lowering and bisoprolol. In severe cases, surgery is indicated.

Angina is one and the most common form of heart disease, it occurs due to a decrease in blood flow to the heart. In other words, the heart muscle does not receive enough oxygen.

The leading cause of development in 95-98% of all cases - atherosclerosis. Less angina occurs as a result of vasospasm.

The pain of angina pectoris is often triggered by physical activity or emotional stress.

Angina in Russia suffer 4-7% of people aged 45-65 years and 10-15% of people older than 65 years.

Risk factors

• Age older than 65 years;
• Male gender (in young and middle aged men suffer more frequently with age, the incidence becomes the same)
• Cases of the disease in the family;
• Smoking;
• Arterial hypertension;
• Lipid profile: high concentration cholesterol low density lipoprotein (LDL);
• Sugar diabetes;
• Sedentary lifestyle;
• Obesity - a body mass index greater than 25 kg / m2. The most dangerous is the abdominal type of obesity. About him can testify waist circumference greater than 88 cm in women and more than 102 cm in men .;
• Alcohol abuse;
• Increased heart rate;
• Disturbances in the blood coagulation system, such as increased clot formation;
• Frequent or severe stress.

manifestations

Currently shared 3 types of angina:

• stable angina (angina);
• vasospastic (variant, Printsmetalla);
• silent myocardial ischemia.

stable angina pectoris

Most often found in patients with stable angina, which occurs in response to physical or emotional burden and can be triggered by other conditions involving palpitation and increased blood pressure.

The most important symptom of angina - occurrence retrosternal discomfort at the time of exercise and cessation of pain in 1-2 minutes after decreasing the load.

Important! Pain attack lasting more than 15 minutes, require the intervention of a doctor and call an ambulance.

The attack is not perceived as an obvious pain, but as trudnovyrazimy discomfort, which can be described as heaviness, squeezing, tightness, compression or a dull ache.

Retrosternal localization of pain radiating to the left shoulder and arm is most typical. In most cases, the pain starts in the chest behind the breastbone and away in all directions. The pain usually starts behind the upper part of the sternum than the lower part of it. Less commonly, it begins on the left near the sternum, in the epigastric region, in the left shoulder or the left shoulder.

Well known irradiation of pain in the left shoulder blade, neck, face, jaw, teeth, and in the right shoulder and right shoulder blade. Described rare cases of giving pain in the left side of the waist and the left part of the abdomen, lower limbs.

The intensity and duration of pain varies considerably in different patients. They are not strongly dependent on the number of diseased arteries of the heart and the extent of their losses. However, in one and the same patient with stable angina diseases are comparable with each other, in the absence of disease progression.

Angina pain grow gradually as successive attacks burning all amplifying and compressing. Reaching its climax, which is always roughly the same intensity for a given patient, the pain quickly disappears. Duration period pains rise always greatly exceeds the duration of the period of their disappearance.

Sometimes there is rapid breathing, pale skin, dry mouth, increased blood pressure, heart palpitations, urinary urgency.

attack duration in angina pectoris is almost always more than one minute and usually less than 15 minutes. The most common attack of angina lasts 2-5 minutes. The attack will be shorter and less intense if the patient immediately stops the load and take nitroglycerin. Thus, if the angina caused by physical stress, duration and intensity to a certain extent depend on the patient's behavior. If the angina attack came in response to emotional stress, when the patient is unable to to control the situation, the attack can be prolonged and more intense than in response to physical load.

For angina is characterized by provoking the attack by frost and cold wind, which is particularly often observed in the morning when leaving the house.

Angina can progress. Tolerance (tolerance) to physical activity may decrease over time. It depends on many factors, but primarily on the patient's adherence to treatment.

Angina functional classes

Stable angina pectoris is divided into four functional classes according exercise tolerance:

1. Usual daily physical activity does not cause angina attacks and only when symptoms of severe stress described earlier.
2. Slight limitation of physical activity - attacks occur at fast walking, climbing stairs, overeating, cold or windy weather.
3. A significant limitation of physical activity - characteristic pain occur when walking over a distance of 1-2 blocks on level terrain or climbing stairs at a normal pace after 1 passage.
4. Inability to perform any physical activity without symptoms or angina can occur at rest.
5. If the patient avoids exposure factors causing the pain, the angina attacks occur less frequently.

If the load (brisk walking, climbing stairs) does not cause the chest discomfort, with the big probability we can assume that the patient is no significant destruction of major coronary arteries heart.

Pain, the duration of which is measured in seconds (less than one minute), typically have extracardiac origin. In most cases, prolonged bouts of pain for hours, if not developed myocardial infarction, not related to the involvement of large coronary arteries and have a different origin.

vasospastic angina

A number of patients can be identified special form of angina pectoris (vasospastic or variant angina, Prinzmetal angina type). It named for the physician, one of the first who described it as an independent form of angina in 1959. It arises as a result of pronounced spasm of the vessel.

For this form of angina (Prinzmetal type) is characterized by attacks of pain arising at rest, which are accompanied by non-permanent signs of damage ECG infarction departments.

Painless form of myocardial ischemia

In most cases, myocardial ischemia are asymptomatic. Quite often identified cases where myocardial put "hindsight" that is, under the planned film on electrocardiography revealed foci of necrosis and in further communication with the doctor found out that people did not even feel any symptoms, which somehow could point to happened.

Painless form of myocardial ischemia can be detected using diagnostic methods that assess the heart function at rest, during exercise and after it.

Diagnostics

To identify angina are important complaints of the patient, since often it is manifested typical symptoms. Despite this, physicians must verify their suspicions and make a differential diagnosis with a whole list of diseases, which may have similar symptoms (pulmonary, digestive, nervous system diseases, psychiatric, endocrine diseases and others). For this purpose, a variety of research methods

laboratory methods

• general blood analysis (Possible leukocytosis; decrease in hemoglobin during non-coronary causes of symptoms).
• biochemical blood tests (increased cholesterol and LDL, A reduced level of HDLIncrease performance glucose),
• markers of myocardial damage (troponins) with altered character attacks (myocardial suspected)
• analysis of thyroid hormones.

instrumental

Invasive (these procedures are carried out only in a hospital):

• coronary angiography (X-rays of blood vessels using a contrast agent, is often combined with surgical treatment for coronary artery disease - stenting)
• intravascular ultrasound (imaging of atherosclerotic plaques in the coronary vessels, is rarely used because of the low accessibility of the art)
• transesophageal electrostimulation (for diagnosis of latent coronary insufficiency in the inability to use non-invasive examination methods).

Non-invasive:

• ECG (ischemic changes);
• daily monitoring Holter;
• ECG exercise (treadmill or bicycle ergometry test on a treadmill);
• Echocardiography (Echocardiography) alone;
• Echocardiography with pharmacological or exercise;
• Radionuclide methods (substance is distributed in the myocardial tissue and clearly visualize areas with insufficient blood supply);
• MRI of the heart (When visualization problems via echocardiogram).

First aid for angina

Nitroglycerin and its analogues

Nitroglycerin - a recognized, best-known and most effective drug to relieve angina attacks. When you receive a dose of 0.3-0.5 mg sublingual nitroglycerin clearly interrupts angina. The drug is placed under the tongue, and he resolves within one minute. The concentration of nitroglycerin in the blood reaches a maximum after 4-5 minutes and began to decrease after 15 minutes. Nitroglycerin can be repeated 2 more times.

Widespread drugs nitroglycerin spray - 1 dose under the tongue corresponds to 1 tablet of nitroglycerin.

In current clinical guidelines RF alternatively nitroglycerin recommended for use isosorbide dinitrate¹.

Important! If the attack does not subside within 10-15 minutes after the re-taking nitroglycerin, you need to call an ambulance and take an analgesic, as a protracted attack may be the first manifestation of myocardial infarction. Usually angina attack docked through 5, a maximum of 10 minutes.

angina treatment

The main place in the treatment of the disease is the work with risk factors, mainly - it is non-pharmacological methods of prevention of cardiovascular complications. Primarily, these include:

• lifestyle changes;
• smoking cessation;

angina Diet

• Reduction of animal fat intake to 30% of the total energy value of food.
• Reducing the intake of saturated fat to 30% of the total fat. cholesterol consumption to 300 mg / day.
• Replacing saturated fats to polyunsaturated and monounsaturated vegetable and marine origin.
• Increased consumption of fresh fruits, plant foods, cereals.
• Limiting the total number of calories in overweight consumption.
• Reduction of salt intake and abstinence from alcohol for high blood pressure.

Physical exercise

Increased physical activity are strictly individually according to their tolerance of the patient. Recommended the following exercise: brisk walking, jogging, swimming, cycling, skiing, tennis, volleyball, dance with aerobic exercise.

The frequency of the heart rate should be no more than 60-70% of the maximum for a given age.

The duration of exercise should be 30-40 min .:

• 5-10 min. warm-up,
• 20-30 min. aerobic phase,
• 5-10 min. the final phase.

Regularity 4-5 times a week (for longer sessions - 2-3 times a week).

Recent studies have shown that exercise combined with a more efficient intake ranozalina - increases endurance, and the number of angina attacks reduced²

When a body mass index greater than 25 kg / m² you need to weight loss through diet and regular exercise. This leads to lower blood pressure, reduce the concentration of cholesterol in the blood.

Body mass index is calculated as follows: BMI = m / h * h, where m - the weight in kg, h - height in meters. For example, BMI = 126kg / 1,83m * 1,83m = 37.

medication

• When high blood pressure is prescribed antihypertensive agent with no effect on non-drug treatment. The optimum blood pressure less than 140/90 mm Hg. Article .;
• In the presence of diabetes necessarily take lipid-lowering drugs prescribed by the doctor-endocrinologist and diet strictly.

For removal of angina, as mentioned above, nitroglycerin is used.

Antiplatelet drugs - aspirin (75-150mg / day) or clopidogrel (aspirin intolerance) - shown in all patients diagnosed with angina pectoris. They reduce the risk of arterial thrombosis, thereby reducing the risk of myocardial infarction.

Lipid-lowering agents

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

Beta-blockers in the treatment of angina pectoris

The therapeutic efficacy of beta-blockers for angina pectoris is due to their ability to reduce myocardial oxygen consumption, in whereby, despite the increase in vascular tone matching is achieved between the need for oxygen and its delivery to tissue infarction.

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

ACE inhibitors are indicated in patients after myocardial infarction with signs heart failure or left ventricular dysfunction³.

A recent critical review of the recommendations of the European Society of Cardiology of the University of Oklahoma Health Sciences Center also confirms the effectiveness of such therapy⁴.

Surgery

A major role now belongs to the surgical treatment of angina. For this purpose methods revascularization (reperfusion) infarction. These include:

• CABG - complicated surgery on the heart vessels to bypass the constriction via vascular prostheses.
• percutaneous intervention - stenting (lumen recovery vessel by posing a stent within a vessel or carcass).

The main indications for surgery - severe angina and for the lack of effect of drug therapy.

forecasts

According to statistics, the annual death rate from coronary heart disease (angina and in particular) does not exceed 3.2% worldwide. On the long-term prognosis affect the degree of coronary artery disease, duration or exercise tolerance, and co-morbidities. The published data does not take into account the presence or absence of a therapy (e.g., statins and aspirin) that reduce mortality.

In general, patients with stable angina have a good prognosis provided that the diet and dispensing exercise. However, the prognosis for individual patients can vary in the presence of risk factors (e.g., presence of diabetes or obesity), and other diseases.