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Stenocardia – the IBS form which is characterized by pristupoobrazny pains in heart owing to sharp insufficiency of blood supply of a myocardium. Distinguish tension stenocardia arising at physical or emotional activities and the rest stenocardia arising out of physical effort, more often at night. Except pains behind a breast it is shown by feeling of suffocation, pallor of integuments, pulse rate fluctuations, feelings of interruptions in work of heart. Can cause development of heart failure and myocardial infarction.

Stenocardia

Stenocardia – the IBS form which is characterized by pristupoobrazny pains in heart owing to sharp insufficiency of blood supply of a myocardium. Distinguish tension stenocardia arising at physical or emotional activities and the rest stenocardia arising out of physical effort, more often at night. Except pains behind a breast it is shown by feeling of suffocation, pallor of integuments, pulse rate fluctuations, feelings of interruptions in work of heart. Can cause development of heart failure and myocardial infarction.

As display of an ischemic disease stenocardia occurs almost at 50% of patients, being the IBS most frequent form. Prevalence of stenocardia is higher among men – 5-20% (against 1-15% among women), with age its frequency sharply increase. Stenocardia, in view of specific symptomatology, is also known as "angina pectoris" or a coronary heart trouble.

Development of stenocardia is provoked by sharp insufficiency of a coronary blood-groove owing to which the imbalance between the need of kardiomiotsit for intake of oxygen and its satisfaction develops. Violation of perfusion of a cardiac muscle leads to her ischemia. As a result of ischemia oxidizing processes in a myocardium are broken: there is an excess accumulation of nedookislenny metabolites (dairy, coal, pyrogrape, phosphoric and other acids), ionic balance is broken, ATP synthesis decreases. These processes cause at first diastolic, and then and systolic dysfunction of a myocardium, electrophysiological violations (changes of a segment of ST and a tooth of T on the ECG) and, finally, development of painful reaction. The sequence of the changes happening in a myocardium carries the name of "the ischemic cascade" which cornerstone violation of perfusion and change of metabolism in a cardiac muscle is, and the final stage is development of stenocardia.

Oxygen insufficiency is especially sharply felt as a myocardium during emotional or physical pressure: for this reason stenocardia attacks happen during the strengthened work of heart more often (during physical activity, a stress). Unlike a sharp myocardial infarction at which in a cardiac muscle irreversible changes develop at stenocardia disorder of coronary blood circulation has passing character. However if the hypoxia of a myocardium exceeds a threshold of its survival, then stenocardia can develop into a myocardial infarction.

Reasons and risk factors of stenocardia

The leading reason of stenocardia, as well as coronary heart disease, the narrowing of coronary vessels caused by atherosclerosis is. Attacks of stenocardia develop when narrowing a gleam of coronary arteries for 50-70%. Than vyrazhenny the atherosclerotic stenosis, that proceeds stenocardia heavier. Severity of stenocardia also depends on extent and localization of a stenosis, on the number of the affected arteries. The pathogenesis of stenocardia often has the mixed character, and along with atherosclerotic obstruction processes of a tromboobrazovaniye and spasm of coronary arteries can take place.

Sometimes stenocardia develops only as a result of an angiospazm without aterosklerozirovaniye of arteries. At a number of pathologies of digestive tract (diafragmalny hernia, cholelithiasis, etc.), and also infectious and allergic diseases, syphilitic and rheumatoid defeats of vessels (aortit, periarteriit, vaskulit, endarteriit) the reflex cardiospasm caused by violation of the highest nervous regulation of coronal arteries of heart - so-called, reflex stenocardia can develop.

Development, progressing and display of stenocardia are influenced by (removable) and not modified (ineradicable) risk factors modified.

The sex, age and heredity belong to not modified risk factors of stenocardia. It was already noted that men are most subject to risk of developing of stenocardia. This tendency prevails up to 50-55 years, i.e. before menopausal changes in a female body when production of estrogen – the female sex hormones "protecting" heart and coronary vessels decreases. After 55 years stenocardia occurs at persons of both sexes approximately with an equal frequency. Often stenocardia is observed at the direct relatives of the patients who are suffering from IBS or had a myocardial infarction.

On the modified risk factors of stenocardia of people has an opportunity to affect or exclude them from the life. Quite often these factors are closely interconnected, and reduction of negative impact of one eliminates another. So, reduction of fats in the consumed food leads to decrease in cholesterol, body weight and arterial pressure. Removable risk factors of stenocardia are among:

  • Giperlipidemiya

Increase in cholesterol, etc. the lipidic fractions possessing atherogenous action is found in 96% of patients with stenocardia (triglycerides, lipoproteins of low density) that leads to adjournment of cholesterol in the arteries feeding a myocardium. Increase in a lipidic range, in turn, strengthens processes of a tromboobrazovaniye in vessels.

  • Obesity

Usually arises at the persons eating high-calorific food with the excessive content of animal fats, cholesterol and carbohydrates. Patients with stenocardia need restriction of cholesterol in food to 300 mg, to table salt – to 5 g, increase in the use of food cellulose – more than 30 g.

  • Hypodynamia

Insufficient physical activity contributes to development of obesity and violation of lipidic exchange. Influence at once of several factors at the same time (a hypercholesterolemia, obesity, a hypodynamia) plays a crucial role in developing of stenocardia and its progressing.

  • Smoking

Smoking of cigarettes increases in blood concentration of carboxyhemoglobin – compound of the carbon monoxide and hemoglobin causing oxygen starvation of cages, first of all kardiomiotsit, a spasm of arteries, increase HELL. In the presence of atherosclerosis smoking promotes early display of stenocardia and increases risk of development of a sharp myocardial infarction.

  • Arterial hypertension

Often accompanies a current of IBS and promotes progressing of stenocardia. At arterial hypertension because of increase systolic HELL increases tension of a myocardium and his need for receiving oxygen increases.

  • Anemia and intoxications

These states are followed by decrease in delivery of oxygen to a cardiac muscle and provoke stenocardia attacks, both against the background of coronary atherosclerosis, and at its absence.

  • Diabetes

In the presence of diabetes the risk of IBS and stenocardia increases twice. Diabetics with a 10-year experience of a disease have the expressed atherosclerosis and have the worst forecast in case of development of stenocardia and a myocardial infarction.

  • Increase in relative viscosity of blood

Promotes processes of a tromboobrazovaniye in the place of development of an atherosclerotic plaque, increases risk of thrombosis of coronary arteries and development of dangerous complications of IBS and stenocardia.

  • Psychoemotional stress

Heart at a stress works in the conditions of the raised loading: develops , HELL increases, supply of a myocardium with oxygen and nutrients worsens. Therefore the stress is the powerful factor provoking stenocardia, a myocardial infarction, sudden coronary death.

Also include immune reactions, dysfunction in number of risk factors of stenocardia an endoteliya, the increased heart rate, a premature menopause and reception of hormonal contraceptives at women, etc.

The combination of the 2nd and more factors, even expressed moderately, increases total risk of development of stenocardia. Existence of risk factors has to be considered when determining medical tactics and secondary prevention of stenocardia.

Classification of stenocardia

On the international classification accepted by WHO (1979) and the All-Union Cardiological Scientific Center (AUCSC) of the USSR Academy of Medical Sciences (1984) allocate the following types of stenocardia:

1. Tension stenocardia - proceeds in the form of passing attacks of the zagrudinny pains caused by the emotional or physical activities increasing metabolic requirements of a myocardium (tachycardia, increase HELL). Usually pains disappear at rest or are stopped by nitroglycerine reception. Stenocardia of tension includes:

For the first time the arisen stenocardia – lasting up to 1 month from the first manifestation. Can have various current and the forecast: to regress, pass into the stable or progressing stenocardia.

Stable stenocardia – lasting over 1 month. On ability of the patient to transfer physical activities it is subdivided into functional classes:

  • The I class – good tolerance of usual physical activities; development of attacks of stenocardia is caused by the excessive loadings which are carried out is long and intensively;
  • The II class – usual physical activity is a little limited; emergence of attacks of stenocardia is provoked by walking on the flat area more than to 500 m, rise on a ladder more than to 1 floor. Cold weather, wind, emotional excitement, the first hours after a dream exert impact on development of an attack of stenocardia.
  • The III class – usual physical activity is sharply limited; attacks of stenocardia are caused by walking at habitual speed on the flat area on 100-200 m, rise on a ladder on 1 floor.
  • The IV class – stenocardia develops at the minimum physical activity, walking less than on 100 m, among a dream, at rest.

The progressing (unstable) stenocardia – increase in weight, duration and frequency of attacks in response to loading, habitual for the patient.

2. Spontaneous (special, vazospastichesky) stenocardia – caused by a sudden spasm of coronary arteries. Attacks of stenocardia develop only at rest, at night or early in the morning. The spontaneous stenocardia which is followed by raising of a segment of ST is called alternative, or Printsmetal's stenocardia.

Progressing, and also some options spontaneous and for the first time the arisen stenocardia unite in the concept "unstable stenocardia".

Stenocardia symptoms

Typical symptom of stenocardia are pains behind a breast, is more rare more to the left of a breast (in a heart projection). Pain can be squeezing, pressing, burning down, sometimes – cutting, pulling, drilling. Painful intensity can be from tolerant to very expressed, forcing patients to groan and shout, feel fear of near death.

Pains irradiate mainly in the left hand and a shoulder, the lower jaw, under a left shoulder-blade, to the epigastralny area; in atypical cases – in the right half of a trunk, leg. Irradiation of pain at stenocardia is caused by its distribution from heart to the VII cervical and to the I—V chest to segments of a spinal cord and further on centrifugal nerves to the innervated zones.

Pain at stenocardia arises at the time of walking, rise on a ladder, efforts, a stress more often, can arise at night. The attack of pain proceeds from 1 to 15-20 minutes. The factors facilitating a stenocardia attack are nitroglycerine reception, a standing position or sitting.

During an attack the patient suffers a shortage of air, tries to stop and stand, presses a hand to a breast, turns pale; the person accepts suffering expression, the top extremities grow cold and grow dumb. In the beginning pulse becomes frequent, then urezhatsya, development of arrhythmia is possible, increase HELL is more often than premature ventricular contraction. The prolonged attack of stenocardia can develop into a myocardial infarction. As the remote complications of stenocardia serve the cardiosclerosis and chronic heart failure.

Diagnosis of stenocardia

At recognition of stenocardia consider complaints of the patient, character, localization, irradiation, duration of pains, conditions of their emergence and factors of knocking over of an attack. Laboratory diagnostics includes a research in blood of the general cholesterol, nuclear heating plant and ALT, lipoproteid of high and low density, triglycerides, laktatdegidrogenaza, kreatinkinaza, glucose, a koagulogramma and electrolytes of blood. Definition of kardialny troponin of I and T - the markers demonstrating injury of a myocardium has the special diagnostic importance. Identification of these miokardialny proteins speaks about the occurred microheart attack or a myocardial infarction and allows to prevent development of postinfarction stenocardia.

The ECG removed at stenocardia attack height reveals decrease in a ST interval, existence of a negative tooth of T in chest assignments, violations of conductivity and a rhythm. Daily ECG monitoring allows to record ischemic changes or their absence at each attack of stenocardia, ChSS, arrhythmia. The heart rate increasing before an attack allows to think of tension stenocardia, normal ChSS – of spontaneous stenocardia. at stenocardia reveals local ischemic changes and violations of a sokratimost of a myocardium.

Velgoergometriya (VEM) is the test showing what maximum load the patient without threat of development of ischemia can transfer. Loading is set by means of the exercise bike before achievement of the submaximum ChSS with simultaneous record ECG. At negative test the submaximum ChSS is reached in 10-12 min. for lack of clinical and ECGs displays of ischemia. The test which is followed at the time of loading by an attack of stenocardia or with a shift of ST segment at 1 and more than a millimeter is considered positive. Detection of stenocardia is also possible by induction of controlled passing ischemia of a myocardium by means of functional (chrezpishchevodny stimulation of auricles) or pharmacological (izoproterenolovy, tests with dipiridamoly) load tests.

Stsintigrafiya of a myocardium is carried out for the purpose of visualization of perfusion of a cardiac muscle and identification in it focal changes. Radioactive medicine thallium is actively absorbed by viable kardiomiotsita, and at the stenocardia which is followed koronarosklerozy focal zones of violation of perfusion of a myocardium come to light. Diagnostic coronary angiography is carried out for assessment of localization, degree and prevalence of damage of arteries of heart that allows to be defined in the choice of a way of treatment (conservative or surgical).

Treatment of stenocardia

It is directed to knocking over, and also the prevention of attacks and complications of stenocardia. As medicine of first aid at an attack of stenocardia serves nitroglycerine (on a piece of sugar to hold in a mouth to a full rassasyvaniye). Pain relief usually comes in 1-2 minutes. If the attack was not stopped, nitroglycerine can be reused with an interval of 3 min. and no more than 3 times (in view of danger of sharp falling HELL).

Planned medicamentous therapy of stenocardia includes reception of the antianginalny (anti-ischemic) medicines reducing the need of a cardiac muscle for oxygen: nitrates of the prolonged action (a pentaeritritil of tetranitrate, dinitrate Isosorbide, etc.), b-adrenoblokatorov (an anaprilina, an oksprenolola, etc.), a molsidomina, blockers of calcic channels (verapamil, nifedipine), a trimetazidin, etc.;

In treatment of stenocardia use of anti-sclerous medicines (group of statin - a lovastatin, a simvastatin), antioxidants (tocopherol), antiagregant is expedient (acetilsalicylic to - you). According to indications prevention and treatment of violations of conductivity and a rhythm is carried out; at stenocardia of a high functional class the surgical revaskulyarization of a myocardium is carried out: balloon angioplasty, aortocoronary shunting.

Forecast and prevention of stenocardia

Stenocardia is chronic invalidiziruyushchey heart pathology. When progressing stenocardia the risk of development of a myocardial infarction or a lethal outcome is high. Systematic treatment and secondary prevention promote control of the course of stenocardia, improvement of the forecast and preservation of working capacity at restriction of physical and emotional activities.

Effective prevention of stenocardia requires an exception of risk factors: decrease in excess weight, control for HELL, optimization of a diet and way of life etc. As secondary prevention at already established diagnosis of stenocardia it is necessary to avoid disorders and physical efforts, preventively to accept nitroglycerine before loadings, to perform prevention of atherosclerosis, to carry out therapy of the accompanying pathologies (diabetes, gastrointestinal diseases). Exact following to recommendations about treatment of stenocardia, reception of the prolonged nitrates and dispensary control of the cardiologist allow to reach a condition of long remission.

Stenocardia - treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!

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