An attack of angina pectoris is a feeling of discomfort behind the sternum that occurs when there is an imbalance between myocardial oxygen demand and its delivery through a narrowed coronary artery .
Angina pectoris is a clinical syndrome manifested by a feeling of discomfort or pain in the chest of a compressing, pressing character, which is localized most often behind the sternum and can radiate to the left arm, neck, lower jaw and up the abdomen.
During an attack of angina pectoris, patients, as a rule, are not verbose and the localization of pain is indicated with a palm or fist pressed to the sternum (Levin’s symptom).
The main factors that provoke chest pain:
increased blood pressure (BP);
plentiful food intake;
The duration of the painful attack is up to 10 minutes (usually 3-5 minutes), which is stopped after the causative factor stops acting or with the help of nitroglycerin within a few minutes.
Epidemiology and risk factors
In 2006 / mortality from diseases of the circulatory system in the Russian Federation amounted to 56.5% in the overall structure of mortality. Of these, about half is accounted for by mortality from coronary heart disease (CHD). Stable angina is one of the clinical manifestations of the chronic course of ischemic heart disease, which is based on atherosclerosis of the coronary (cardiac) arteries. Therefore, they have common risk factors: male sex, age, high cholesterol, arterial hypertension, tobacco smoking, diabetes mellitus, low physical activity, overweight.
The incidence of angina pectoris increases dramatically with age:
in women from 0.1-1% at the age of 45-54 years to 10-15% at the age of 65-74 years;
in men from 2-5% at the age of 45-54 years to 10-20% at the age of 65-74 years.
Reasons for the development of angina pectoris
At the heart of an attack of angina pectoris is an imbalance between myocardial oxygen demand and its delivery, which in the overwhelming majority of cases is associated with a narrowing of the atherosclerotic plaque of the lumen of the coronary (cardiac) artery by more than 50-70%. In this case, the length, localization, quantity and type of this narrowing also matter.
Diagnosis of angina pectoris
Interviewing a patient by a cardiologist
The clinical diagnosis of angina pectoris is based on the data of a detailed survey and a careful study of the history of the disease (anamnesis). All other research methods are used to confirm or exclude a diagnosis, clarify the severity of the disease, prognosis, and evaluate the effectiveness of treatment.
calculating body mass index (BMI);
determination of heart rate;
heart rate parameters;
BP on both arms;
assessment of signs of atherosclerosis (xanthomas and xanthelasmas, senile corneal arch, arterial stenosis);
degenerative changes in the valves of the heart;
additional heart sounds on auscultation.
All these data are assessed by a cardiologist during the consultation.
They are used to assess risk factors and identify concomitant diseases (complete blood count, lipid metabolism, glucose, creatinine, ALT / AST, thyroid hormones, etc.).
These are examinations performed to confirm the diagnosis of coronary artery disease, identify its complications, assess the cardiovascular risk and prognosis of the patient’s life.
About half of patients with angina that has been confirmed with other methods have a normal electrocardiogram ( ECG ). At the same time, the detection on the ECG of data indicating myocardial hypertrophy, the presence of a pathological Q wave (scar) or changes in the ST / T segment, increase the likelihood of angina pectoris. Conduction disturbances (AV and intraventricular blockade) also occur in patients with coronary artery disease, but are characterized by low specificity in the diagnosis of angina pectoris.
Exercise testing may be required to increase the diagnostic value of the study.
- Echocardiography (ECHO-KG, ultrasound of the heart)
ECHOCARDIOGRAPHY (ultrasound of the heart ) is a highly informative and safe method of cardiac imaging, which allows assessing not only structural, but also functional changes in almost all cardiovascular diseases. The peculiarity of the study is that it allows non-invasively with a high degree of reliability to assess hemodynamics, anatomy of the walls of the heart and its valves, large vessels, as well as the systolic and diastolic function of the myocardium, which is especially important before any surgical interventions.
The main purpose of ECHO-KG for angina pectoris is differential diagnosis with non-coronary (not due to atherosclerosis of the heart arteries) chest pain that occurs with aortic valve defects, hypertrophic cardiomyopathy, heart failure, enlargement of the aorta or pulmonary artery, etc.
- Perfusion myocardial scintigraphy with stress
The method is based on the principle that a radionuclide (thallium-201 and technetium-99-m) introduced into the body is distributed in the heart muscle during circulation and reflects the regional state of blood flow in the heart.
This method is highly sensitive in detecting coronary artery disease, however, it is invasive and expensive, therefore it is used in specialized centers when the diagnosis is difficult using the previous methods.
Tasks of treating patients with angina pectoris
The main objectives of the treatment are:
Control of risk factors, reducing the likelihood of the formation of new atherosclerotic plaques;
Reducing the risk of complications associated with thrombosis;
Reducing the risk of death and increasing life expectancy with the help of measures that reduce myocardial ischemia;
Improving the quality of life.
At the same time, it is very important that a cardiologist prescribes treatment from the standpoint of evidence-based medicine, using drugs that solve the above problems.
Antiplatelet drugs – primarily aspirin. Aspirin remains the mainstay of prevention of arterial thrombosis. The dose of aspirin should be as effective as possible to ensure a balance between therapeutic effect and possible gastrointestinal side effects. The optimal dose of aspirin is determined by your doctor. Regular intake of aspirin by patients with angina pectoris, especially those who have had a heart attack, reduces the risk of developing a second heart attack by an average of 23%.
Lipid-lowering drugs (lowering cholesterol) – statins. These drugs reduce the risk of atherosclerotic complications (heart attack, stroke, etc.) both before the disease and the development of a second one. The results of a meta-analysis of 16 studies using statins for stable angina pectoris showed a reduction in the risk of all-cause mortality by 22%, mortality from all cardiovascular diseases by 28%, and from ischemic stroke by 29%.
Control of myocardial ischemia
Nitrates (short and long-acting) – for relief of an attack, it is advisable to use aerosol forms with a more accurate dosage due to the constant concentration of the drug, and for the prevention of angina attacks, preference is given to prolonged preparations of isosorbide dinitrate and especially isosorbide-5 mononitrate, which has 100% bioavailability (delivery to the body).
Targeted beta-blockers – improve life prognosis and have antianginal properties (prevention of seizures). The optimal dose is selected by a cardiologist to reduce the heart rate by 20% or provide a heart rate of 50-60 beats at rest.
Thus, most patients, especially middle-aged ones, are not aware of the presence of coronary artery disease, since the heart can begin to “signal” its illness only when it has been reduced in nutrition by 70-75% in the form of angina pectoris, or acutely, by the sudden onset of such formidable manifestations of ischemic heart disease, such as myocardial infarction or sudden death.