Rest stenocardia – the attacks of sudden zagrudinny pain arising for lack of obvious provocative factors. The attack of stenocardia develops in the conditions of physical rest, is characterized by duration and considerable expressiveness of anginozny pains, suffocation, vegetative reactions, fear of death. Diagnosis of stenocardia of rest includes laboratory inspection, the ECG, ultrasonography of heart, coronary angiography, heart PET. Emergency aid at stenocardia of rest consists in sublingual reception of nitroglycerine; further to the patient planned reception of nitrates, antitrombotsitarny medicines, beta , statin, antagonists of calcium, APF inhibitors is appointed. According to indications the myocardium revaskulyarization (coronary angioplasty, AKSh) is carried out.
Rest stenocardia (dekubitalny, posturalny stenocardia) – one of clinical forms of coronary heart disease which is characterized by the heavy attacks of angina pectoris arising at rest out of communication with physical tension. Rest stenocardia in cardiology is considered as unstable stenocardia and develops at patients with the IV functional class of a disease. As separate options of stenocardia of rest are allocated Printsmetal's stenocardia caused by a sharp unexpected spasm of coronary arteries and the postinfarction stenocardia developing within 10-14 days after the postponed myocardial infarction.
On a current I distinguish subsharp stenocardia of rest (in the presence of attacks within the last month) and sharp stenocardia of rest (in the presence of attacks within the last 48 hours). Rest stenocardia predictively is more dangerous, than tension stenocardia, and leads to a heavy complication of IBS more often – to a myocardial infarction.
Rest stenocardia reasons
As the main reason for stenocardia of rest serves coronary atherosclerosis. At rest stenocardia heavy (more often three-vascular) damage of coronal arteries usually takes place. As a morphological substratum of dynamic coronary obstruction serves the atherosclerotic plaque which is quite often complicated by thrombosis and an arterial spasm. Stenocardia of rest joins tension stenocardia in process of progressing of narrowing of a gleam of coronary vessels, making heavier a current of the last.
Except atherosclerotic defeat, developing of ischemia of a myocardium can be promoted by other diseases which are followed by increase in need of a cardiac muscle for oxygen: arterial hypertension, a hypertrophic cardiomyopathy, a stenosis of the mouth of an aorta, koronarit, partial obstruction of coronary arteries of a tromboembolama or syphilitic gumma, etc. As rest stenocardia attacks in most cases develop during sleep, it is supposed that the pathogenesis of a disease is caused by increase in a tone of the wandering nerve.
Development of stenocardia of rest is quite often promoted by the states aggravating myocardium ischemia (fever, anemias, a hypoxia, infections, takhiaritmiya, diabetes, a thyrotoxicosis). Among not modified (ineradicable) risk factors of stenocardia are considered age 50-55 years, a menopause at women, Caucasian race, heredity are more senior; obesity, smoking, a hypodynamia, a metabolic syndrome, the increased viscosity of blood, etc. belong to the modified (potentially removable) factors.
Rest stenocardia symptoms
Attacks of anginozny pain at stenocardia of rest develop against the background of full physical tranquility when the person is in horizontal position in a bed, a thicket during sleep or early morning hours. The role of the peculiar loading causing myocardium ischemia at stenocardia of rest carries out increase in venous inflow to heart in a prone position.
The sudden attack of stenocardia of rest forces the patient to wake up from sharp suffocation or feeling of a sdavleniye in a breast. Attacks of stenocardia of rest arise in a REM sleep phase when there are dreams therefore often the patient reports that in a dream it had to run or lift weights quickly. According to modern representations, the phase of a REM sleep represents the endogenous stress which is followed by excitement of the autonomic nervous system and emission of catecholamines.
The attack of stenocardia of rest is followed by a condition of the increased alarm, concern, fear of death. The pain syndrome has sharply intensive character; pains are localized behind a breast, have the squeezing, pressing character, extend to a jaw, a shovel, the left hand. Pain forces the patient to stand in one situation as the slightest movement inflicts intolerable suffering. The Anginozny attack differs in the bigger duration (5-15 minutes) and weight, in comparison with tension stenocardia; quite often its knocking over requires reception of 2-3 tablets of nitroglycerine.
Against the background of an anginozny attack the expressed vegetative reactions develop: tachycardia, rise HELL, breath increase, perspiration, sharp pallor or hyperaemia of integuments, nausea, dizziness. In most cases night episodes of stenocardia of rest are accompanied by tension stenocardia at physical activity in the afternoon. The rest stenocardia attack which dragged on up to 20-30 minutes and also strengthening or increase of anginozny pains demands immediate hospitalization and observation of the patient by the cardiologist.
Diagnosis of stenocardia of rest
The patient with stenocardia of rest needs stationary inspection with carrying out a full complex of clinical laboratory and tool diagnostics. On the ECG at rest stenocardia the rise or a depression of a segment of ST demonstrating existence of a critical stenosis of a coronary artery, violation of a rhythm and conductivity of heart usually comes to light; signs of a postinfarction cardiosclerosis (pathological tooth of Q and negative tooth of T).
Conducting load tests (a veloergometriya, the tredmil-test) at rest stenocardia not always informatively – results can be negative. Often symptoms of ischemia manage to be revealed only during daily ECG monitoring. To all patients with stenocardia of rest EhoKG allowing to estimate sokratitelny ability of a myocardium, to find the accompanying cardiac pathology is carried out. The minimum biochemical blood test includes determination of level of the general cholesterol, lipoproteid of high and low density, nuclear heating plant and ALT, triglycerides, glucose; analysis of a koagulogramma.
For assessment of a condition of coronary arteries and definition of medical tactics performance of x-ray coronary angiography or its modern modifications is shown to all patients with stenocardia of rest (KT-coronary angiography, multispiral KT-of coronary angiography). For identification of sites of ischemia and assessment of coronary perfusion heart PET (a positron and issue tomography) is carried out. It is necessary to distinguish pains at pleurisy from stenocardia of rest, intercostal neuralgia, gullet diverticulums, hernia of an esophageal opening of a diaphragm, an ulcer and cancer of a stomach.
Treatment of stenocardia of rest
Approach to treatment of stenocardia of rest includes non-drug actions for correction of a way of life, medicinal therapy, surgical intervention for a myocardium revaskulyarization. The behavior model at stenocardia of rest demands refusal of tobacco smoking, alcohol intake and energy drinks; observance of a diet with restriction of cholesterol, animal fats, caffeine, salt; decrease in excess body weight.
At a bad anginozny attack rest, immediate reception of nitroglycerine under language is necessary. At the prolonged not stopped attack the call of "ambulance" is required. Planned treatment of stenocardia of rest is carried out by medicines of various groups; antitrombotsitarny medicines (acetilsalicylic are usually appointed to - that), beta (, , propranolol), statins (, ), APF inhibitors (enalaprit), antagonists of ions of calcium (nifedipine, verapamil), nitrates (nitroglycerine, isosorbide mononitrate or isosorbide dinitrate).
At rest stenocardia, as a rule, there are indications to cardiac treatment. As operation of the choice serves balloon angioplasty and stenting of coronary arteries. Results of coronary angioplasty are high – at patients anginozny attacks stop, sokratitelny function of a myocardium improves. Emergence of a restenoz - repeated narrowing of an artery is in certain cases possible.
At crushing or multiple damage of arteries performing aortocoronary shunting with creation of alternative ways for a coronary blood-groove is shown. At 20-25% of the patients who transferred AKSh, stenocardia renews within 8-10 years that demands repeated operation of aortocoronary shunting.
Forecast and prevention of stenocardia of rest
The forecast at stenocardia of rest is more serious, than at tension stenocardia: it is caused more expressed and, as a rule, by multiple damage of coronary arteries. Such patients have higher risk of development of a myocardial infarction and sudden warm death.
Scheduled maintenance demands full elimination of the modified risk factors, treatment of associated diseases. All patients with stenocardia of rest have to be observed constantly at the cardiologist and if necessary to be consulted by the heart surgeon.