STENOCARDIA

From Big Medical Encyclopedia

STENOCARDIA (Greek stenos narrow, close + kardia heart; synonym: angina pectoris, angina pectoris) — the symptom of acute ischemia of a myocardium which is expressed an attack of pains behind a breast. In a wedge, practice there was a relation to S. as to independent a wedge, to the syndrome demanding emergency treatment what was promoted, in particular, a possibility of a failure of an attack (a myocardial infarction, fibrillation of ventricles), and also a frequent combination of pain to emotions of fear, disturbance of vegetative functions (cold sweat, changes of the ABP, etc.).

According to the recommendation of WHO experts (1979), S. carry to manifestations coronary heart disease (see). Allocate S. of tension, to-ruyu subdivide on for the first time arisen, stable and progressing; Page of rest (spontaneous S.); the special form C. which is often designated as Printsmetal's stenocardia. On the basis of the frequency of emergence of attacks and their dependence on an exercise stress of S. divide into several forms: an easy form (attacks arise seldom, at exercise or psychoemotional stresses, excessive for this patient); medium-weight form when development of attacks is connected with daily professional or household loadings and it is seldom observed at rest; a severe form with frequent attacks daily or numerous during the day at the slightest physical tension and at rest.

A wedge, pictures C. W. Heberden in 1768 for the first time gave the detailed description: «Those who are subject to it (angina pectoris) during the walking, especially after food, have painful most unpleasant feelings in a breast, to-rye, apparently, will take away life if only amplify or will proceed, but once you stop, this constraint disappears. In all other relations patients at the beginning of this disease feel well and, as a rule, there is no shortened breath, from to-rogo this state completely differs». Already W. Heberden knew that S.'s attacks can arise at defecation, at disorders, and also at rest, in a prone position that in the winter the disease proceeds heavier, than in the summer that men get sick more often 50 years with an excess weight are more senior. It described irradiation of pains in the left hand, cases of sudden death during an attack. Parri (S. N. of Parry, 1799) assumed that pains at angina pectoris are caused by reduction of supply of heart with oxygen. Leytem (R. M. of Latham, 1876) considered that the spasm coronary (coronal, T can be S.'s cause.) arteries. At the same time there were views of S. as on a disease of a nervous system. R. Laennek (1826) called S. neuralgia of heart. Establishment of communication of S. with pathology of coronary arteries and S.'s differentiation with a myocardial infarction was clinically important (see) at its intravital diagnosis. In 1918 G. Bousfild published data on changes of an ECG at S. V 1959 Mr. Prin-tsmetal (M. of Prinzmetal) described a special form C. In the 60th 20 century of idea of S.'s pathogeny extended due to studying of influence on heart simpatiko-adrena-lovoy system and catecholamines, to-rye, according to W. Raab, can cause S.'s emergence, increasing the need of a myocardium for oxygen. In the same years data on mechanisms of self-control of a tone of coronary arteries extended, the role of their spasm in development of an attack at nek-ry forms C. is proved, also possibilities of differential diagnosis of S. and painful attacks, similar to it, which are not relating to manifestations of coronary insufficiency (a so-called cardialgia) increased.

Being rather specific symptom of the coronary heart disease (CHD), S. is observed, however, not in all cases of this disease. At a single-step eggidemiol. the examination of one of the districts of Moscow conducted among men at the age of 50 — 59 years, the ischemic heart disease is revealed at 18,8% inspected, and S. of tension — at 11,4%. Observation within 4,52 — 5 years of accidentally chosen persons among the population of New York (4% of 110 thousand inhabitants) at the age of 35 — 64 years showed that the frequency of emergence of S. of tension made at men 2,03 and at women 0,92 on 1000 inspected in a year. In rare instances S. is connected with the coronary insufficiency (see) caused not by an ischemic heart disease, and defeat of coronary arteries at other diseases, in particular a vasculitis at rheumatism, a nodular feather arteritis, a syphilitic mesaortitis. Disturbances of a coronary blood-groove at considerable decrease in the diastolic ABP in an aorta can be S.'s cause, in particular at aortic incompetence, considerable decrease in cordial emission (e.g., at an aortal stenosis, heart failure). S.'s development is promoted by disturbance of transport function of blood (anemia, a poisoning with carbon monoxide), increase in viscosity of blood (erythremia), the anoxemia connected with a pulmonary disease or decrease in the oxygen content in inhaled air.

The pathogeny

Formation of an attack of S. is connected with irritation of nervous receptors in a zone of ischemia of a myocardium products of the broken metabolism. The probability of emergence of S. of subjects is higher, than ischemia is expressed more, i.e. than discrepancy between inflow of blood to a myocardium and its metabolic requirements is more. In an essential measure degree of ischemia is defined by expressiveness of atherosclerosis of coronary arteries. In experimental conditions the blood stream in a coronary artery remains normal until its cross-section does not decrease by 85% that corresponds to reduction of the area of a gleam approximately for 75%. It is provided with expansion of the arterioles located distalny a stenosis. Given to a coronary angiography and the results of researches received during operation of shunting of coronary arteries demonstrate that stenozirovany arteries, the reaching 50% of its gleam, seldom are followed by S.; during the narrowing of a gleam for 75% of S. arises often; at S. which was more expressed to a stenozirovaniya (90 — 100% of a gleam) develops also in the conditions of rest. Developing of ischemia of a myocardium and S.'s attack is in a feedforward with the size of the cardiac performance (defining metabolic requirements), edges increases at the exercise stresses and emotional pressure which are followed by increase of serdtsebiyeniye and increase in the ABP. During the conducting functional load trial on the stationary bicycle (see Elektrokardiografiya) S. arises at achievement of a certain size of the work of number of cordial reductions and the average ABP, edge of an eye-syvayetsya of a constant for this patient. The size of cardiac performance is influenced also by a condition of an endocardiac and general hemodynamics. Increase in end diastolic pressure and diastolic volume of a left ventricle increases tension developed by it and, therefore, oxygen requirement; besides, in these conditions blood supply of subendo-cardial layers of a myocardium worsens. Loading on the stationary bicycle is worse transferred in horizontal position when the venous inflow to heart is increased, the diastolic volume and end diastolic pressure increase in a left ventricle. Thanks to the existing mechanisms of regulation of a coronary blood-groove increase in need of a myocardium for oxygen leads at healthy faces to expansion of coronary arteries and adequate increase in inflow of blood to a myocardium. At patients with atherosclerosis of coronary arteries the same expansion of not struck arterial branches can lead to redistribution of a blood-groove: generally blood comes to the sites supplied by neskle-rozirovanny arteries, and receipt it through stenosed branches sharply decreases (a phenomenon of interkoronarny «burglarizing»). The Dilati-rovanny vessels located distalny a stenosis, losing the tone, gain properties of passive tubes and easily are exposed to compression during the strengthening of cordial activity and systolic tension of a myocardium, at increase in final diastolic volume and pressure in a left ventricle. It aggravates ischemia of the site of the myocardium supplied by the sclerosed arteries.

The spasm of coronary arteries caused by disturbance of regulation of their tone, in particular excitement of alpha adrenoceptors of walls of large branches of coronary arteries at activation of sympathoadrenal system (at a stress, hypothalamic dysfunction, at introduction by the patient and-adrenomimetikov) or change of reactivity of walls of arteries owing to their atherosclerotic defeat can be the reason of passing ischemia of a myocardium and S. The role of a spasm of coronary arteries is shown, e.g., at Printsmetal's stenocardia. The spasm of a coronary artery which is followed by S.'s attack, raising of a segment S T on an ECG can be provoked by intracoronary introduction to the patient during coronary angiography of alkaloid of an ergot of ergometrine. The Ergometrinovy spasm arises in places of hypersensitivity of smooth muscles of a coronary artery that not always matches localization of a zone of the ischemia caused in the same patient with an exercise stress on the stationary bicycle (when ischemia usually develops in the sites corresponding to the greatest organic narrowing of a coronary artery). Therefore existence of two forms C. at one patient differing on the pathogenetic mechanism is possible.

Hyper activation of sympathoadrenal system at a stress promotes development of a hypoxia of a myocardium and S. not only through and - adrenergiche-skiye mechanisms. The increased emission of catecholamines (see) and stimulation of p-adrenoceptors of heart increase its work and oxygen requirement at insufficient relaxation of a myocardium in the period of a diastole. Besides, increase in coagulability of blood with the increased adhesion of thrombocytes (at the same time viscosity of blood increases and resistance to a blood-groove increases in vessels) and release of the thromboxane possessing vasopressor action is noted; F2a prostaglandin, allocation to-rogo perhaps in connection with activation has the same effect at a stress kinin-kal-likreinovoy systems. Metabolism of a myocardium in a zone of ischemia is sharply broken; for emergence of pain, i.e. actually S., accumulation in the hypoxemic site of a myocardium of lactic acid, strengthening of hydrogen ions, extracellular potassium, polypeptides matters.

In heart there are undifferentiated sympathetic receptor terminations located between cells. They unite with not - the myelinized fibers, to-rye perivaskulyarno pass to a cardiac plexus. It is supposed that S.'s attack is caused by irritation of nerve terminations polypeptides, in particular kininam (see), to-rye are released in the conditions of ischemia when the cellular environment becomes more acid or the maintenance of potassium ions increases. Impulses on touch fibers of sympathetic nerves of heart go to gangliya between Soup and ThIV, then come to a spinal cord (communication with somatic nerves), go back to a thalamus and in zones of perception of a cerebral cortex. Expressiveness of pain depends on extent of changes of metabolism in a myocardium (proportional to degree of ischemia) and on a condition of nerve terminations; painful attacks can disappear after a myocardial infarction when in an affected area there is a destruction of nerve terminations. Localization of the pain felt at S. usually corresponds to zones of an innervation from verkhnegrudny segments, but in some cases there is pain of atypical localization.

Pathological anatomy

In most cases morfol. S.'s basis is atherosclerosis of coronary arteries of heart. The microscopic picture and ultrastructure of a myocardium at S. are studied insufficiently in connection with short duration of ischemia. In an experiment symptoms of ischemia of a myocardium can be revealed in a few minutes after its approach. The intracellular glycogen disappears, and there is a relaxation of myofibrils. These changes are reversible if ischemia proceeds no more than 30 min. According to a puncture biopsy of a myocardium (see. Heart ), at ischemic heart disease patients dystrophic changes of organellas of myocytes, generally membrane systems of a cell, and to a lesser extent — the myofibrillar device are revealed. Along with dystrophy in nek-ry myocytes signs of intracellular regeneration come to light (existence of kernels and euchromatin in kernels, free ribosomes, the policy and a granular reticulum in a sarcoplasm).

The clinical picture and a current

In typical cases of S. is characterized by an attack of pain of the squeezing or pressing character, the localized thicket in the field of an upper part of a breast, sometimes to the left of it. Pains can irradiate in the left hand, in the left half of a neck and person, in a mandible, the left ear, to the area of a left shoulder-blade, sometimes in the right shoulder or both shoulders and both hands, a back. Less often pain extends in the left part of a stomach and waist, in legs. The beginning of pain seldom happens sudden, usually it gradually accrues, several minutes keep. then disappears. It is characteristic bystry (within 2 — 3 min.) stopping of pain nitroglycerine. Intensity painful feeling depends on specific features of the patient. Many patients complain not of pain, and of heavy feeling, prelums or constraint behind a breast, shortages of air. S.'s attack can be followed by sensation of fear, sometimes the general weakness, perspiration, a tremor, occasionally feeling of faintness, faints, dizziness, desires on an urination and a plentiful diuresis. At inspection of the patient sometimes no aberrations are found. At the time of an attack pallor of skin can be observed. In some cases reveal hypersensitivity of skin in places of irradiation of pain.

Medical inspection of the patient during S.'s attack does not reveal essential dynamics in action of the heart. The sizes of heart are not changed; at auscultation insignificant weakening of cardiac sounds, pathological III tone, systolic noise can be only sometimes recorded, to-rye disappear after an attack. The attack can be followed by insignificant tachycardia (see) or bradycardia (see), occasionally premature ventricular contraction (see), and the last is especially characteristic of Printsmetal's stenocardia, increase in the ABP.

Emergence of pains at an exercise stress is characteristic of S. of tension, in particular during the walking; the patient is forced to stop then pain in 2 — 3 min. stops. Especially badly patients transfer walking against wind, to cold weather. The act of defecation can provoke S.'s attack, its emergence is promoted by plentiful food, abdominal distention. The page of tension can arise also at the emotional loadings increasing the need of a myocardium for oxygen owing to emission of catecholamines, increase in cardiac performance because of increase in the ABP and increase heartbeat.

The page of rest is characterized by emergence of attacks without visible communication with exercise or emotional stress. Development of an attack at night during sleep is typical. The patient wakes up from feeling of a prelum behind a breast or suffocation, sits down in beds. Quite often S.'s attacks of rest proceed is longer and heavier, than S.'s attacks of tension. In most cases S. of rest develops at patients with sharply expressed, often stenosing, atherosclerosis of coronary arteries. At such sick S. of rest it is combined with S. of tension. At a part of patients with S.'s diagnosis of rest in the course of observation communication of attacks with loading — increase in the ABP and increase of number of cordial reductions (comes to light at night during a bystry phase of a dream), increase in volume of the circulating blood at patients with the latent or explicit heart failure at night. These forms have the same pathogeny, as S. of tension, but tolerance to an exercise stress at the same time is sharply reduced. Sometimes the attack of stenocardia arises at the time of transition of the patient to horizontal position (angina decubitus) that is explained with increase in venous return (preloading).

A part in S.'s emergence of rest can be played patol. reflexes from interoretseptor of various bodies. Speak about actually reflex S. in cases when attacks are undoubtedly connected with reflex influences: inhalation of a cold air (a reflex from respiratory tracts), cooling of skin (so-called S. of cold sheets), an exacerbation of cholelithiasis (holetsisto-koronar-ny a reflex) etc.

Typical S. of tension and rest is called classical stenocardia. Along with it allocate the special form C. which is usually designated as Printsmetal's stenocardia; it is caused by a periodic spasm of one of large coronary arteries without increase in metabolic requirements of a myocardium before an attack. This form occurs at 2 — 3% of sick Pages. Emergence of pains is not connected with exercise or emotional stress, but they can be provoked by cooling, drink of a cold water, an overeating, smoking, a hyperventilation. Individual recurrence in development of attacks is characteristic, to-rye a thicket arise at night or at daybreak. As well as at classical S., pains are localized behind a breast, but duration can reach them 20 — 30 min. Quite often the attack is followed by plentiful sweating, sometimes nausea, vomiting. Nek-ry patients can have several attacks in a row with an interval between them from 2 — 3 to 10 — 15 min. Printsmetal's stenocardia can arise as at patients with not changed coronary arteries, and in the presence of coronary atherosclerosis. In the latter case it can be combined with S. of tension. The complication of stenocardia of Printsmetal various frustration of a rhythm and conductivity is possible; ventricular extrasystoles, a total and incomplete atrioventricular block (see. Heart block ). Heavy disturbances of a cordial rhythm can be the cause of sudden death of the patient.

At sick S.' part proceeds atypically. Pain is sometimes localized not behind a breast, and in the left or right hand, a shoulder, epigastric area, a mandible, i.e. in places, in to-rye the retrosternal pain quite often irradiates at typical S. V such cases it is necessary to think of S. if pain of atypical localization arises during the walking and disappears at the termination of loading.

In some cases acute coronary insufficiency is shown not by attacks of pains, but other symptoms equivalent S. Ekvivalent S., especially at is long the ill people or after the postponed myocardial infarction, there can be an emergence of feeling of shortage of air or the complicated breath during walking in the absence of strong indications of heart failure; at sharply expressed cardiosclerosis acute coronary insufficiency in some cases is shown not by typical attacks of S., and in the form of cardiac asthma (see) - an asthmatic equivalent of S. — or a fluid lungs (see). The paroxysm can sometimes be S.'s equivalent ciliary arrhythmia (see), emergence of frequent ventricular extrasystoles, Bouveret's disease (arhythmic equivalent of S.).

The current

Severity of S. is defined by the frequency, weight and duration of painful attacks; the less loading, the provoking S., the is more degree of coronary insufficiency. S.'s current can be stable when attacks arise under the same circumstances, and their frequency depends on a way of life and loads of the patient. Progressing, or unstable, S. is characterized by increase, increase in weight and duration of attacks (the quantity of Tabulettaes Nitroglycerini, accepted by the patient per day usually increases, sometimes nitroglycerine becomes inefficient); sometimes S. of rest join S. of tension. Carry to unstable S. also for the first time the arisen S. (prescription up to 1 month, in the subsequent the stable current can accept edges or precede development of a myocardial infarction), and also long (up to 15 — 30 min.) the anginous attack which is not stopped nitroglycerine with changes of an ECG like focal dystrophy, but without characteristic for myocardial infarction (see) datas of laboratory, and Printsmetal's stenocardia in a phase of an aggravation if the last attack was no later than 1 months ago. If unstable S.'s current comes to the end with development of a myocardial infarction, retrospectively speak about a preinfarctive state.

Diagnosis

the Electrocardiogram is normal (and) and its most typical changes at test with the subgross exercise stress at the healthy person (b) and at the patient with stenocardia during an attack (in, and e): — the slanting ascending decrease in a segment of ST, in — the slanting descending decrease in a segment of ST, reduction of a tooth of T; — horizontal deep shift down a segment of ST, two-phases-nost of a tooth of T; d — inching of a segment of ST, a tooth of T negative, isosceles, has the pointed top.

In S.'s diagnosis an important role is played by carefully collected anamnesis and detailing of complaints of the patient. The pristupoobraznost and short duration of pain, its communication with physical tension, localization behind a breast (in typical cases), bystry effect of nitroglycerine are most essential. Datas of laboratory during an attack do not change. Electrocardiographic and vektorkardiografichesky shifts during attacks come to light at 50 — 70% of patients. The most characteristic changes on an ECG are the depression of a segment of ST and reduction of amplitude, flattening or inversion of a tooth of T; becomes frequent it negative or two-phase (fig., in, and e), sometimes increases to a huge sharp-pointed tooth. Passing disturbances of a rhythm and conductivity can be fixed. Out of an attack of an ECG it can be not changed. The elevation of a segment of ST is typical for Printsmetal's stenocardia during an attack that it testifies to transmural ischemia of a myocardium. At incomplete vasoconstriction or partial compensation of a blood-groove the depression of a segment of ST is possible. Repeated attacks of stenocardia of Printsmetal proceed usually with identical changes of an ECG in the same assignments. At long monitor overseeing by the patients suffering from this form C. episodes of bezbolevy increase in a segment of ST are observed that is also caused by a spasm of coronary arteries. On a vektorkardiogramma (see. Vektorkardiografiya ) during S.'s attack the loop of T most often changes, it deviates and goes beyond a loop of QRS, forming with it a corner to 60 — 100 °, and at the expressed hypoxia — to 100 — 150 °, at the same time the closure failure of a loop of QRS is noted.

As registration of an ECG during an attack is not always possible S., for detection of coronary insufficiency use functional load trials. Treat the dosed exercise stress on the stationary bicycle or the tredmil them (see. Ergografiya ), electric stimulation of auricles and pharmakol. tests with izoprenaliny or a dipyridopier (see. Elektrokardiografiya ). Tests are applied both to diagnosis of an ischemic heart disease, and to definition of tolerance to an exercise stress. Contraindications for conducting these tests are a myocardial infarction in the acute period, frequent attacks of S., heart failure, high the ABP, arrhythmias of heart, an aortal stenosis. A relative contraindication — a gross obesity, emphysema of lungs, a pulmonary heart. Positive, i.e. testimonial of a hypoxia of a myocardium, consider the following changes during loading: 1) emergence of an attack of S. with simultaneous changes of an ECG or without them; 2) emergence of a heavy asthma or suffocation; 3) decrease in the ABP; 4) ECG signs: horizontal or arc-shaped shift of a segment is S T up or down on 1 — 2 mm, emergence of a negative tooth of T, especially at simultaneous decrease in height of a tooth of R; the slanting ascending shift of a segment S T down, a cut happens also at healthy faces (fig., b), but is regarded as a sign of coronary insufficiency if duration of decrease in a segment S T more than 0,08 sec. with a depth of shift not less than 1,5 mm; 5) developing of frequent polytopic and especially early ventricular premature ventricular contraction or disturbances of atrioventricular conductivity. At emergence of one of these signs or at substantial increase of the ABP loading is stopped. The basis for the termination of loading is also achievement of the pulse rate corresponding to the level of a submaximum load. Such pulse rate, by criteria of WHO (1971), at the age of 20 — 29 years makes 170 blows in 1 min., at the age of 30 — 39 years — 160, at the age of 40 — 49 years — 150, at the age of 50 — 59 years — 140, in 60 years and is more senior — 130 blows in 1 min. If achievement of the submaximum pulse rate is not followed by clinical or electrocardiographic signs of ischemia of a myocardium, test is considered negative that it, however, does not disprove the diagnosis of an ischemic heart disease, though does it doubtful.

False positive results happen at patients to heart diseases, to arterial hypertension and a hypertrophy of a left ventricle, at vegetovascular dysfunction, at reception of cardiac glycosides, diuretics, estrogen. Loading on the stationary bicycle allows to estimate also the power and volume of the performed work. Electric stimulation of auricles gives the chance to bring number of cordial reductions to the submaximum level without increase in the ABP and without participation of peripheral factors. As the method is invasive, it is seldom used in a wedge, practice.

The same electrocardiographic and clinical criteria are used at the method of frequent electric stimulation of auricles which is seldom carried out, but having a number of advantages (a possibility of the immediate termination of tachycardia).

Use pharmakol. tests with izoprenaliny and Dipiridamolum it is based on what R-adrenostimu-lyator izoprenalin increases the need of a myocardium for oxygen and increases cardiac performance, and Dipiridamolum causes ischemia of a myocardium, krovosnabzhayemy the sclerosed arteries, due to expansion of not affected arteries (a phenomenon of «burglarizing»). Administration of these drugs by the patient with coronary atherosclerosis causes emergence of symptoms of ischemia on an ECG. Apply alkaloid of an ergot to identification of a spasm of coronary arteries ergometrine. At the same time at the patients having Printsmetal's stenocardia on an ECG raising of a segment of ST is registered, sometimes there is a painful attack, at patients from classical S. the depression of a segment of ST or an attack of pains without changes of an ECG is possible that it indicates participation of a spastic component in genesis of attacks of Page. For diagnosis of atherosclerotic narrowing of coronary arteries it is used coronary angiography (see). Indications for its carrying out — an estimated operative measure or considerable diagnostic difficulties.

A X-ray contrast or radionuclide ventrikulografiya give the chance to find sites of a hypokinesia, an akineziya or dyskinesia of an ischemic myocardium. Local disturbances of contractility of a myocardium owing to his ischemia come to light with the help echocardiography (see). After reception of nitroglycerine the zone of a hypokinesia can decrease or disappear. Ischemia of the site of a myocardium is found also with the help stsintigrafiya (see) with thallium-201, absorption to-rogo tissue of a myocardium in an ischemic zone is reduced. A pyrophosphate technical-netion-99 or a technetium-99-tetratsik-lean, on the contrary, collect in the centers of ischemia of a myocardium or its necrosis that is used for the diagnosis.

Differential diagnosis carry out between S.'s attack and a myocardial infarction (see), and also between S. and pains in heart of a nekoronarogenny origin — so-called cardialgias. It is necessary to think of a myocardial infarction if S.'s attack proceeds more than 30 min. and is characterized by a megalgia if S. is followed by decrease in the ABP, the cardiac asthma expressed by dynamics of cordial tones. In such cases the diagnosis is specified by means of an electrocardiography. Cardialgias can meet at diseases of a myocardium, a pericardium or a pleura, to have a psychogenic origin, can be caused by pathology of the musculoskeletal device or a peripheral nervous system, went. - kish. path, diaphragm. As a rule, at cardialgias, unlike S., there is no accurate pristupoobraznost of pains, they can last for hours and days, often happen aching, pressing, puncturing. Pains not behind a breast, and in the field of a top of heart are localized, there are no accurate communication with an exercise stress, walking, effect of nitroglycerine. At inflammatory diseases (myocarditis, a pericardis) corresponding changes of datas of laboratory are found, at a pericardis (see) the pericardial rub is listened. At diseases of a musculoskeletal system and neuralgia characteristic painful points, sometimes rentgenol come to light. changes, pains are quite often provoked by the sharp movements of the left hand, an inconvenient pose, stopped by analgetics. At diseases went. - kish. a path it is necessary to pay attention to communication of pains with food, emergence them in horizontal position after food (at hernia of an esophageal opening of a diaphragm). Help with diagnosis special endoscopic and rentgenol. methods of a research. People of middle and advanced age have cardialgias in connection with osteochondrosis of a backbone, endocrine disturbances, etc. can be combined with an ischemic heart disease and S.

Treatment

apply nitroglycerine To stopping of an attack of S. (a tablet on 0,0005 g under language or 1% spirit solution, 1 — 3 drops on sugar). Nitroglycerine removes a spasm of coronary arteries, lowers their resistance and has thereby coronarodilator effect. Under its influence the blood stream on collaterals and quantity of the functioning branches increases, the chamber pressure and volume of ventricles of heart decreases that reduces tension of walls of a myocardium and their pressure upon arteries and collaterals in an ischemic zone. Besides, nitroglycerine reduces peripheric arterial resistance and causes dilatation of veins that leads to hemodynamic unloading of a left ventricle and decrease in oxygen consumption by a myocardium. Effect of nitroglycerine is shown in 1 — 2 min. and 20 — 30 min. last. Side effects of nitroglycerine — the pulsing headache, sometimes decrease in the ABP. These phenomena can be eliminated with reduction of a dose of drug or its use as a part of Votchal's drops (9 h 5% of menthol alcohol and 1 p.1 of % of nitroglycerine). At prolonged attacks apply narcotic and non-narcotic analgesics, to-rye enter parenterally. Angiospastic stenocardia, or Printsmetal's stenocardia, is most accurately stopped by sublingual reception of nifedipine (Corinfarum). S.'s stopping is promoted also by use of mustard plasters on area of heart, immersion of hands in hot water (reflex influence from receptors of skin on coronary vessels). Patients with unstable S. shall be hospitalized, it is desirable in the block of an intensive care.

At a persistent current of S. the issue of an operative measure is resolved, the purpose to-rogo consists in elimination of the painful attacks reducing working ability of the patient, increase in cardiac effeciency and in prevention of a myocardial infarction at patients from the heavy S. of rest and tension which is not giving in to medicamentous therapy. For this purpose make the revascularization of a myocardium which is considered by absolutely shown patient with unstable (preinfarctive) S., having atherosclerotic defeats of a trunk of the left coronary artery, the critical stenoses (more than 75% of a gleam) of a front interventricular artery, damage of three main arteries of heart proksimalno located with a passable distal bed.

The operative measure which is carried out in the conditions of artificial circulation (see) and the Cold cardioplegia (see), consists in shunting of an affected area of a coronary artery by means of aortocoronary autovenozny shunts (see Atherosclerosis, surgical treatment of occlusal defeats; Myocardial infarction, surgical treatment) or internal chest arteries (see Arterialization of a myocardium). The last operation is made less often in connection with advantages of operation of multiple shunting (see Shunting of blood vessels). At the same time quite often use one «jumping» autovenozny shunt with a consecutive anastomosis with several coronary arteries. Single shunting is shown to hl. obr. at the isolated damage of a front interventricular artery; in this case with success carry out also endovascular dilatation of the site of a stenosis limited on extent without performing open surgery on heart (see Rentgenoendovasku-lyarnaya surgery). At repeated operations or in the absence of a qualitative autogenic transplant allogenic or xenogenic vascular bioprostheses use synthetic (core-tex).

The most terrible complication of operations — intraoperatsionno arisen myocardial infarction (see) with development in the postoperative period of cardiogenic shock (see). Prevention of this complication consists in carrying out high-quality protection of a myocardium from anoxic on vrezhdeny during execution of the main stage of operation on the stopped heart (see the Cardioplegia).

The immediate and long-term results are in direct dependence on a reference state of sokratitelny function of a myocardium, completeness of its revascularization, size of a volume blood-groove on the bypass shunt (the blood stream less than 40 — 50 ml/min. predictively is adverse because of danger of thrombosis of the shunt). After direct revascularization of a myocardium at 80 — 95% of patients S.'s attacks almost completely disappear or considerably the need for specific medicamentous therapy decreases, tolerance to an exercise stress increases, working capacity completely is recovered or improves.

Prevention of stenocardia

Primary prevention (see. Prevention primary ). the vast majority of cases of stenocardia comes down to the actions directed to the prevention of development atherosclerosis (see) and coronary heart disease (see). If other diseases are the reason of stenocardia (e.g., rheumatic heart diseases, a syphilitic mesoaortitis, anomalies of development of cardiovascular system, the expressed anemia), prevention of stenocardia is treatment of the corresponding diseases (see. Coronary insufficiency, Heart diseases inborn, the Heart diseases acquired Rheumatism, Syphilis). Secondary prevention includes continuous drug treatment and system of the medical and sports actions applied to improvement of coronary collateral circulation, and also a measure of fight against progressing of the diseases which are the cornerstone of stenocardia.

For prevention of attacks of S. widely use drugs of nitroglycerine of the prolonged action (Sustac, Nitrongum, Trinitrolongum and especially Nitrosorbidum) in individually certain doses, and also other nitrates of long action (aerinite, Nitrosorbidum). The important place in prevention of attacks of S. is taken by beta adrenoblockers (propranolol, Trasicorum, etc.), to-rye reduce the frequency, force and speed of cordial reductions, cordial emission, the ABP and as a result reduce the need of a myocardium for oxygen. Their possible side effects — a bronchospasm, strengthening of heart failure, a hypoglycemia at the patients with a diabetes mellitus receiving glucose-lowering drugs. They are contraindicated at the bronchial asthma which is sharply expressed to bradycardia, an atrioventricular block. At heart failure these drugs are used in a combination with cardiac glycosides or use cardioselective beta adrenoblockers (e.g., kordanum).

If the spasm is the cornerstone of S.'s attack, antagonists of calcium, napr, nifedipine (Corinfarum) are shown. Nifedipine does not influence atrioventricular conductivity, the number of cordial reductions under the influence of nifedipine increases and therefore it is possible to appoint it in combination with beta adrenoblockers. Verapamil (Isoptinum) possesses similar on the mechanism, but less expressed coronarodilator action; it reduces number of cordial reductions, can slow down atrioventricular conductivity therefore it is not combined with beta adrenoblockers.

Antiarrhythmic action is peculiar to Isoptinum. It can be used for prevention of attacks of S. in case of its not heavy current at S.'s combination and premature ventricular contraction. Derivatives of isoquinoline — a papaverine and Nospanum — possess the direct action weakening a vascular wall. They are applied inside to prevention of attacks or parenterally to stopping of prolonged attacks in combination with analgetics. Drugs are shown at the accompanying spastic conditions of bilious ways, intestines, hron. gastritises.

Karbokhromen (Intensainum, Intencordinum) increases a coronary blood stream and at prolonged use promotes development of collaterals. It is applied generally at the localized coronary atherosclerosis since there are data that with the widespread stenosing atherosclerosis drugs of a karbokhromen can cause in patients (especially at parenteral administration) strengthening of pains. Dipiridamolum (Persantinum, curantyl) also increases a collateral blood stream thanks to strengthening of adenosine in a myocardium and reduces aggregation of thrombocytes. However in high doses Dipiridamolum can worsen blood supply of the ischemic site in a zone of a stenosis of an artery because of distribution of blood in expanded vessels (fenokhmen «burglarizing»).

The wedge, application are found also by p-adrenoaktivatory — oxyfedrine (ildamen, Myofedrinum), nonakhlazin, to-rye possess positive inotropic action, increase a coronary blood stream. However they can increase the need of a myocardium for oxygen therefore are applied only at patients with not severe forms of S. without the expressed coronary atherosclerosis at the accompanying arterial hypotension and bradycardia.

The urezheniye of attacks of S. is promoted by peripheral vazodilatato-ra, in particular a pier and the domain (box-vaton), to-ry increases the capacity of venous system, reduces a venous inflow of blood to heart, reducing load of heart and oxygen consumption; drug slows down also aggregation of thrombocytes.

For decrease in need of a myocardium for oxygen use piridoksinil-glioksilat (glio-6, gliosiz), to-ry activates anaerobic and slows down aerobic processes, having protective action on ultrastructures of a myocardium at a hypoxia.

Quite often there is a need for appointment of psychoheadlights-makol as sick S. means (sedative, somnolent, tranquilizers, antidepressants).

Emergence of a large number of effective anti-anginal remedies, first of all nitrates of the prolonged action and a r-adrenoblokato-ditch, reduced value of preventive use at S. of a papaverine, Nospanums, anti-thyroid drugs. Treatment planning and selection of drugs is defined by clinic and weight of a current of an ischemic heart disease, depends on a phase of a disease, existence of complications and the accompanying pathology.



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E. I. Sokolov, I. E. Sofiyeva; S. L. Dzemeshkevich (hir.).

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