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Stenocardia is an attack of suddenly developing and usually quickly passing thorax pains. Pains are most often localized behind a breast or on its left edge, sometimes extend to the left half of a thorax, almost never arise in the right half of a thorax. On character of pain most often happen stupid, pressing, squeezing, sometimes burning, drilling, extremely intensive. Pains can extend to the left shoulder, a forearm, is more often on an internal surface of a hand, reaching the IV—V fingers of a brush. Irradiation in a back under a left shoulder-blade, in a mandible, a neck, an anticardium is less often noted. Extremely seldom pain is felt only in zones of irradiation or begins from here, extending to a thorax. Sometimes, a thicket at women, pains can have atypical localization and arise in upper part of the left half of a thorax or in the field of a heart top.
Duration of a painful attack makes from several seconds to 10 — 15 min. Most often pain develops during physical tension, for example, when walking, but can arise at mental work, after emotional overloads, when cooling, after plentiful food, and also at rest.
If pains are connected with physical or intellectual tension, then at the termination of the effort which caused emergence of an attack, pain quickly calms down.
Emotional coloring is inherent in an attack of angina pectoris (stenocardia). This feeling of internal alarm, melancholy, depression up to feeling of danger, fear of death. Impossibility to continue the physical movement and fear define behavior of the patient during an attack: he as if stiffens, being afraid to make physical or emotional effort.
The fast effect of reception of nitroglycerine which kills pain within several minutes is typical for stenocardia.
At objective inspection of the patient during an attack vegetative manifestations can be caught: pallor, perspiration, nausea. Pulse usually does not change. Cardiac sounds usually do not change. Arterial pressure can increase a little. In zones of irradiation the hyperalgesia is sometimes noted. Between attacks both in health of the patient, and at survey most often do not find any aberrations. The leading role in recognition of stenocardia is played by inquiry of the patient. If from conversation with the patient the picture of typical stenocardia comes to light, then and further inspection of the patient confirms existence at it to coronary insufficiency.
Clinical forms of stenocardia
Now depending on features of a clinical picture allocate the following forms of stenocardia.
1. Stable stenocardia.
2. Unstable stenocardia,
Depending on a situation in which there is an attack stenocardia is subdivided into an angina of exertion and rest.
Clinically the concept of stability is defined generally by two factors:
• stereotype of conditions of emergence of an attack;
• existence of effect of the termination of physical effort or from nitroglycerine reception.
There is a popular belief that stenocardia can be considered stable if emergence frequency, duration of attacks provoking them factors and possibilities of stopping remain invariable for 60 days.
The pain syndrome at stenocardia of rest is similar to that at an angina of exertion: pain is located behind a breast, has the pressing, squeezing character, similar irradiation. In most cases these patients already have a stable angina of exertion connected with exercise stresses.
Unlike an angina of exertion, stenocardia of rest arises in lying position of the patient at the time of backfilling or at the night of Pain decrease in a sitting position or after nitroglycerine reception. The attack, as a rule, lasts less than 15 min. The role of loading carries out strengthening of a venous inflow (preloading) in a prone position. Thus, stereotype of conditions of emergence, fast effect of change of situation or reception of nitroglycerine, also short duration of an attack allow to carry this type of stenocardia to a stable angina of exertion of very small loadings i.e. to the IV functional class.
Stenocardia of rest can be followed also by others of manifestation mi, connected with ischemia of a cardiac muscle. From heart tachycardia, short wind which can accept a factor of cardiac asthma are not seldom observed; often arterial pressure increases.
Unstable stenocardia designates the period during coronary heart disease corresponding to weighting of coronary insufficiency with possible development of a myocardial infarction (a transitional, intermediate form).
Treatment of stenocardia
Apply nitrates of long action, beta adrenoblockers and antagonists of calcium to the prevention of attacks of stenocardia.
The drugs of nitroglycerine of long action used for the prevention of attacks of stenocardia are so far developed: among them the forms for application on a mucous membrane, for example, Trinitrolongum placed on a gingiva are had; ointment, disks and plasters for cutaneous use, and also drugs for intake (Sustac, nigrong, isosorbide dinitrate and mononitrate).
The choice of medicines or their combination is defined by a current and clinic of an angina of exertion, i.e. a functional class.
So, at sick I—II functional classes monotherapy is usually applied by one of drugs (nitrates, blockers of calcium channels or beta adrenoblockers).
At stenocardia of higher functional classes combine use of drugs with various mechanism of action. The most often applied combinations:
• nitrates and beta adrenoblockers;
• nitrates and antagonists of calcium channels;
• beta adrenoblockers and antagonists of calcium channels of vasodilating action (nifedipine-retard).
The assessment of effect is most often carried out clinically: reduction of frequency of attacks and increase of tolerance to household loadings — walking, rise on a ladder is considered. For objectification of the gained effect use a veloergometriya (increase of tolerance to an exercise stress is registered), and also daily monitoring where reduction of number of ischemic episodes is considered.
At purpose of drugs it is necessary to consider initial hemodynamic indicators, size of arterial pressure, number of cordial reductions. So, at initial bradycardia the combination of nitrates and nifedipine is possible, at tachycardia — nitrates and beta adrenoblockers or verapamil etc.
At low classes of stable stenocardia treatment can incidentally be carried out in the form of courses, and at heavy stenocardia — is almost continuous. Except the above-stated drugs, apply antiagregantny means: aspirin in a dose of 60 — 160 mg a day, in the presence of contraindications to purpose of aspirin - tiklopidin (tiklid), plaviks (klopidogrel).
At inefficiency of medicamentous therapy, high risk of complications including at the asymptomatic course of coronary heart disease the coronary angiography with the subsequent balloon coronary angioplasty or aortocoronary shunting is shown.
Patients with unstable stenocardia are hospitalized in chamber of an intensive care. Treatment of unstable stenocardia and an acute coronary syndrome includes four main groups of drugs: antiagregant (aspirin), direct anticoagulants (unfractionated heparin or low-molecular heparins), beta adrenoblockers and nitrates. Aspirin begin 250 mg with reception, and recommend to chew the first tablet, then on 80 — 160 mg a day for continuous reception.
The myocardium ischemia caused by defeat of coronary arteries can be eliminated by myocardium revascularization. At the same time there are two opportunities: a) endovascular approach — balloon coronary angioplasty and its modifications; b) surgical approach — aortocoronary shunting,
At one-vascular defeat balloon coronary angioplasty while patients with defeat of several vessels or a trunk of the left coronary artery have an aortocoronary shunting is applied. However in practice the question of indications to this or that method of revascularization demands accounting of a set of factors.
Prevention of stenocardia
Weakening of influence of risk factors of coronary heart disease is a necessary condition of secondary prevention of stenocardia.
Secondary prevention of stenocardia includes active impact on risk factors of atherosclerosis and coronary heart disease and the complex treatment directed to improvement of supply of a myocardium with oxygen, reduction of load of heart and increase of tolerance of a myocardium to a hypoxia. Patients have to adhere to a healthy lifestyle, avoid stressiruyushchy influences, stop smoking, keeping to a diet with restriction of the animal fats and products rich with cholesterol. Regular physical trainings with individual selection for intensity and duration are recommended. If the level of cholesterol of lipoproteins of low density exceeds 3,4 mm/l, reception of hypolipidemic drugs is recommended. Arterial hypertension korrigirutsya by the corresponding hypotensive therapy with target arterial pressure not higher than 130/85 mm of mercury. Normalization of body weight is necessary, and the index of body weight should not exceed 24,9 kg/sq.m. In case of a diabetes mellitus glikolizirovanny hemoglobin has to be lower than 7%.