Symptoms, diagnosis and treatment of angina pectoris: what the patient can and cannot do

What kind of disease is this and how is it dangerous?

Angina pectoris is also called “angina pectoris”. This name was first proposed in 1768 by the English physician William Heberden, when he described attacks of angina in his patients: “as if their heart was being squeezed very strongly and suffocated from the inside.”

The most dangerous consequence of long-term angina is myocardial infarction, which ranks first among all causes of death.

Mortality risk for angina pectoris: up to 10% per year.

Pain with angina pectoris develops due to the fact that the heart muscle experiences a sharp lack of oxygen. This is called myocardial ischemia. This occurs due to the narrowing of the blood vessels supplying the heart. In approximately 90-95% of cases, the cause of this is atherosclerosis - the deposition of cholesterol particles on the inner layer of blood vessels and the formation of plaques. The insidiousness of atherosclerosis is that a person’s well-being changes when the lumen of the arteries narrows by more than 50%. Before this he feels quite healthy.

Angina pectoris is a clinical syndrome that is recognized as the most common form of coronary heart disease (CHD). Its prevalence ranges from 30 to 40 thousand per 1,000,000 people. It mainly affects people over 40 years of age, most often men (ratio to women 2.5:1). This division is explained by the fact that female sex hormones have the ability to slow down the development of atherosclerosis. Therefore, the incidence of coronary artery disease among postmenopausal women does not differ from that in men. You can read about gender differences in the course of ischemia here.

Situations that cause the myocardium to require more oxygen than usual predispose to the development of angina. These include high blood pressure (especially hypertensive crisis), rhythm disturbances accompanied by increased heart rate (tachyarrhythmias), various heart defects, diabetes mellitus, anemia, physical inactivity, obesity, bad habits - smoking, alcohol abuse, etc.

High concentrations of cholesterol in the blood are considered one of the main risk factors for coronary artery disease. If your close relatives suffered from coronary heart disease, then the likelihood that you will develop it increases significantly.

In more rare cases, the cause of angina is spasm of the coronary arteries, a congenital anomaly in the structure of the vessels supplying the heart, etc. In ICD-10, angina pectoris is coded I20.0.

Calcium agonists

Calcium agonists - are able to dilate the blood vessels of the heart, increasing the flow of blood to the heart muscle (myocardium), thereby reducing the number of angina attacks

.
They are divided into three main groups with characteristic features. Drugs from the group of dihydropyridine calcium antagonists
(nifedipine) can be prescribed together with beta blockers, or instead of beta blockers (if intolerance or contraindications to the latter).
The first generations (nifedipine) increase the heart rate, so short-acting tablets (nifedipine 10 mg) are prohibited for angina pectoris. There are special prolonged forms (osmo-adalat, corinfar-retard, nifecard) containing from 20 to 60 mg of nifedipine. The third generation of drugs (amlodipine, felodipine) practically does not increase the pulse rate and is taken once a day. Drugs from the verapamil and diltiazem group
reduce the heart rate; combined use with beta blockers is contraindicated due to the risk of bradycardia and other complications. It has been proven that regular use of calcium antagonists can reduce the incidence of strokes.

Symptoms

The main clinical signs of angina pectoris are attacks of pain in the middle of the chest, which are felt as severe squeezing, burning or squeezing. However, this is not the only place where pain occurs. It can radiate to the left arm, neck, shoulder, lower jaw, under the shoulder blade, and upper abdomen. This is a kind of “calling card” of ischemic pain, separating it from all other types. Often these places hurt much more than the heart itself. I have seen patients who were seen by orthopedic traumatologists with a diagnosis of arthrosis of the shoulder joint, although in fact it was angina pectoris.

The duration of the attack varies from 1-2 to 20 minutes. Most often, pain is triggered by physical activity (running, lifting weights, climbing stairs) or emotional stress.

Depending on the degree of stress that causes pain, angina is divided into so-called functional classes (FC) - from 1 (when pain occurs only with very intense muscular work) to 4 (pain can develop even with the slightest movement or at rest).

A distinctive feature of pain during angina pectoris is its disappearance after the person stops exercising or takes Nitroglycerin. In some cases, instead of pain, severe difficulty breathing (shortness of breath) or cough appears.

Recommendations

To prevent angina attacks you must:

• quit smoking
• control cholesterol levels, if necessary, eat a low-fat diet
• perform a dosed and doctor-selected set of physical exercises
• avoid stress
• lead a healthy lifestyle

A balanced diet, dosed physical activity and regular monitoring by a qualified doctor can save a patient with angina pectoris from heart surgery.

How to recognize an angina attack

In most patients, an attack of angina pectoris does not occur “out of the blue.” It must be preceded by some action that increases the myocardial need for oxygen - physical or emotional stress. Pain can also occur when going outside in cold weather, or when the body bends sharply while putting on shoes. Even ordinary overeating leads to the fact that blood flow is redistributed in favor of the digestive system, thereby depleting other organs of blood, incl. and heart.

In my practice, I have met patients in whom the smell of tobacco smoke could cause heart pain.

Often, during an attack, a person becomes covered in cold, sticky sweat, becomes dizzy, and feels nauseous. Some people experience anxiety and fear of death. In such situations, it is very important to distinguish angina pectoris from panic attacks, in which “neurotic symptoms” come first. However, you must always remember that these attacks themselves can cause angina.

If the pain lasts longer than 20 minutes and persists despite taking a nitroglycerin tablet or spray, you should call an ambulance.

You can find out what you need to do during an attack of angina pectoris and how to relieve it at home here.

Canadian classification

To determine the severity of symptoms of angina pectoris, the Canadian Society of Cardiology has developed a special classification in the form of a table, which includes the following functional classes of angina pectoris:

Functional class 1

When performing normal physical activity for a person, he feels good. Pain only appears during intense and prolonged work, such as weightlifting or long-distance running.

Functional class 2

Pain occurs even during normal walking, when a person walks more than 200 meters. Also, angina pectoris develops if the patient climbs stairs above the 2nd floor, goes outside in very cold weather, or overeats.

Functional class 3

The attack begins when walking from 100 to 200 meters, or when climbing to the 2nd floor.

Functional class 4

Doing any physical work causes pain. An attack can develop even in a completely calm state.

Features in men

Males are characterized by the so-called typical clinical picture of angina (burning/pressing pain behind the sternum, developing after physical work). However, pain often makes itself felt too late, and its intensity does not correspond to the degree of damage to the coronary arteries. Those. slight discomfort in men occurs against the background of a pronounced decrease in the lumen of blood vessels.

In other words, the appearance of angina in a man indicates advanced atherosclerosis.

I constantly have to diagnose IHD in men only when they are admitted to the cardiac intensive care unit with myocardial infarction.

FAQ

How to avoid angina pectoris?

To avoid angina pectoris, it is necessary to prevent the development of atherosclerosis if possible, because in the vast majority of cases it is the cause of angina. As is known, many factors directly influence the formation of atherosclerotic plaques. Gender, age, heredity are predisposing factors that cannot be changed, but other factors can be controlled and even prevented:

• high blood pressure
• smoking
• high cholesterol
• overweight
• diabetes
• low physical activity
• stress

Changing these factors is in your hands!

Is it possible to completely recover from angina?

Angina pectoris, as a rule, occurs as a result of damage to the coronary arteries supplying blood to the myocardium by atherosclerosis, and this is a chronic incurable process. However, with a properly selected treatment regimen, it is possible to ensure that long-term remission occurs and angina attacks will not bother you. Also, at present, if necessary, it is possible to install a stent into the narrowed lumen of the vessel to restore blood circulation, or MCS/CABG surgery is a surgical intervention that restores the blood flow of the heart below the site of the narrowing of the vessel. In this surgical procedure, another path for blood flow is created around the narrowing site to the part of the heart that is not supplied with blood.

Where does it hurt during an angina attack?

Characteristic of angina is paroxysmal pain behind the sternum, in the center of the chest. The pain is of a compressive, pressing nature, more often associated with physical or psycho-emotional stress and goes away when it stops. The pain may radiate to the left arm, shoulder blade, lower jaw and collarbone. If nitrates are used, the effect on angina is not delayed, it develops immediately, within 1-2 minutes.

Are there ways to cope with an angina attack without medications?

Since many people experience angina attacks during physical activity, sometimes simply stopping the activity (walking, etc.) and resting can lead to the cessation of pain. However, people suffering from angina pectoris should always have nitroglycerin or nitrospray with them in order to relieve an attack of pain within one to two minutes. You should not delay the time before taking nitroglycerin, since pain is a manifestation of myocardial ischemia (insufficient blood supply), and if it persists, then foci of necrosis may occur in the myocardium (myocardial cells may die). If angina attacks become more frequent, you should urgently consult a cardiologist.

What medications will help with an attack of angina?

An attack of angina must be stopped as soon as possible from the moment of its occurrence, because prolonged ischemia will lead to the development of necrosis, i.e. myocardial infarction. If an attack occurs for the first time in your life, call an ambulance. You can take a nitroglycerin tablet on your own or use a nitro spray under the tongue. The effect will occur within 1-2 minutes and does not last long, 10-15 minutes. It is better to take the drug while sitting or lying down, as a short-term decrease in blood pressure, dizziness, headache, tinnitus may occur - these symptoms are safe and are a consequence of the action of nitroglycerin. If pain returns, you can take nitroglycerin again, because it does not accumulate in the body; multiple doses of the drug are possible during the day (up to 6 tablets per day). If your blood pressure is high, you need to lower it to normal levels.

All patients who have suffered an attack of angina pectoris need to have an ECG performed and a decision by a cardiologist on hospitalization.

Why is it necessary to quit smoking? How does smoking worsen angina?

If you smoke and have angina, the best thing you can do to help your heart is to quit smoking!

Studies have shown that the mortality rate in those patients with angina who quit smoking decreased by 2 times compared to those who continued to smoke. Why? Angina is based on a lack of oxygen in the heart muscle, and smoking increases the level of carbon dioxide in the blood, and it displaces oxygen in the blood. This leads to oxygen starvation of the heart muscle. Smoking also increases blood viscosity. Smoking increases the frequency and aggravation of angina attacks and greatly increases the risk of myocardial infarction. Quitting smoking eliminates the adverse effects of nicotine on the coronary arteries, and angina attacks disappear or become less frequent.

Important: replacing cigarettes with cigars and pipe tobacco, switching to cigarettes with less tar and nicotine do not reduce cardiovascular risk!

Contrary to popular belief, abruptly quitting smoking is not harmful; overcoming this bad habit has an undeniable positive effect, regardless of smoking experience.

You need to be prepared for the fact that sometimes depression and irritability occur when quitting smoking, in which case you can seek help from a psychotherapist.

I suffer from angina pectoris, but I dream of losing excess weight. What physical activities are acceptable for people with such problems?

For people suffering from angina, 30–45 minutes of physical activity per day is recommended. The best choice is walking (preferably at a brisk pace) or Nordic walking with ski poles, cycling, swimming. It is important that the exercises do not cause pain, palpitations, or shortness of breath. When practicing swimming or water aerobics, you should remember that cold water can provoke angina attacks, so the water temperature in the pool should be comfortable for you. It is better to do water aerobics under the supervision of a trainer and according to a program specially adapted for people with cardiac problems. In this case, the loads should increase very gradually. However, to lose weight, you need not only physical activity, but also proper nutrition; a nutritionist will help you choose the right menu during your consultation.

Can you have angina if there is no pain?

Unfortunately yes. For example, with diabetes mellitus, diabetic polyneuropathy develops, and the patient may not feel pain, this is the so-called silent ischemia. This condition is dangerous because the patient does not take action in time, and myocardial infarction will develop. In some cases, shortness of breath during exercise can be considered equivalent to pain, so you can suspect the presence of angina pectoris and come for examination to a cardiologist.

Specifics in women

Unlike men, in women, on the contrary, the pain syndrome is more pronounced with completely satisfactory vascular patency.

I also often observe atypical symptoms of an angina attack in women, i.e. Instead of pain in the heart, the patient experiences a sharp lack of air (asthmatic form), or discomfort in the epigastric region (gastralgic version), which makes it much more difficult to recognize angina pectoris. The nature of pain in women also does not always correspond to the classic one - it can be, for example, stabbing.

Treatment

The goals of treatment are to improve the prognosis (prevent heart attack) and eliminate symptoms of the disease. Non-medicinal (sports, diet), medicinal (tablets and drip infusions) and surgical treatment methods are used.

At the EXPERT Clinic, patients have the opportunity to receive a full consultation with a cardiologist on lifestyle changes and modification of risk factors. If necessary, treatment in a day hospital under the supervision of experienced medical personnel is possible.

What types of angina are there?

Depending on the severity, nature of the course, the cause underlying the mechanism of development of pain and the approach to therapy, the following types of angina are distinguished:

1. Stable (angina pectoris) is the most common type and is divided into FC.
2. Unstable - exacerbation of angina pectoris, or pre-infarction condition. The pain appears even with minimal exertion and does not stop even after taking Nitroglycerin. The process of thrombus formation occurs, but not sufficiently to cause necrosis of the heart muscle. It is considered an emergency condition and its symptoms are indistinguishable from myocardial infarction, but can lead to it. There are the following types of unstable angina:

1. For the first time, the appearance of symptoms of angina pectoris in a person who has not previously experienced such pain. Requires special attention, since proper treatment determines whether the pathology will become stable or progress;
2. Progressive - attacks become longer and more frequent, Nitroglycerin helps less and less (transition from FC I to III or IV in 2 months);
3. Post-infarction – the occurrence of attacks no later than 2 weeks after myocardial infarction. This is the most unfavorable form, as it is characterized by a high probability of death;

1. Vasospastic (variant, spontaneous, Prinzmetal's angina) is angina caused not by atherosclerotic stenosis of the coronary arteries, but by their spasm, i.e. strong contraction of vascular muscles. This type usually occurs in young men. Pain can appear at any time and has nothing to do with physical activity. Most often develops at night or early in the morning. A series of attacks (from 2 to 5), following one after another with an interval of 10 minutes to 1 hour, are specific to this type.

Separately, there is a special type of angina pectoris - cardiac X syndrome, or microvascular angina, in which there are typical attacks of pain during physical effort with ECG signs with normal or slightly changed coronary arteries (vascular patency more than 50%). It is observed mainly in women with neurotic disorders during menopause and premenopause (40-50 years). The exact cause of its occurrence is still unknown.

It is assumed that a decrease in the concentration of female sex hormones (estrogens) leads to spasm of microvessels. It is also important to increase the threshold of pain sensitivity in anxiety and depression.

A distinctive feature of the symptoms of cardiac syndrome X is that attacks of angina pectoris disappear after stopping the exercise, resting or taking Nitroglycerin, but this happens much longer than with other types of angina.

Cytoprotectors

Cytoprotectors

– protects against the death of heart muscle cells during episodes of acute and chronic oxygen deprivation (ischemia), allowing the cells to produce energy to pump the heart using less oxygen.
There is an evidence base for the drug trimetazidine (Preductal MV). The drug has no contraindications (except for individual intolerance) and side effects. Partnership between doctor and patient is the key to successful treatment of angina pectoris.
Still have questions? Make an appointment! Using materials from the article by N.S. Veselkova

Diagnostics

To diagnose angina pectoris, I use the following research methods:

• blood tests;
• electrocardiography;
• ECG with stress;
• daily (Holter monitoring) ECG;
• echocardiography;
• myocardial scintigraphy;
• coronary angiography.

For all patients with attacks of angina pectoris, I prescribe a biochemical blood test to determine the concentration of total cholesterol and its fractions - low and high density lipoproteins. They are also called “bad” and “good” cholesterol. I also check everyone's glucose levels to check for diabetes.

The further examination algorithm has some nuances for different forms of angina. Let's look at these methods in more detail.

In unstable angina, blood is first taken to determine enzymes that indicate necrosis (death) of an area of ​​the heart muscle. These are so-called cardio-specific enzymes. These include troponins I and T, MB fraction of creatine phosphokinase, myoglobin, lactate dehydrogenase. With unstable angina, they are within the normal range or slightly elevated. Their analysis is necessary to exclude myocardial infarction (MI).

Since clinically unstable angina and heart attack are indistinguishable from each other, in practical medical practice they are united by the term “acute coronary syndrome” (ACS).

Electrocardiography is the main instrumental method for diagnosing angina pectoris:

1. Stable - a typical change on the ECG during a painful attack is a decrease in the ST segment by more than 1 mm, sometimes a negative T wave. Since the cardiogram can be normal at rest, to confirm the diagnosis, I prescribe an ECG with a stress test, i.e. during physical exercise - treadmill test (walking or running on a treadmill) and bicycle ergometry (riding an exercise bike).
2. Unstable - characterized by a decrease in the ST segment, but its rise is also possible, which in most cases indicates the development of myocardial infarction.
3. Vasospastic – a specific sign is ST segment elevation at the time of the attack. Conducting stress tests is pointless, since the pain is in no way related to physical effort and occurs at night or early in the morning. Therefore, if this form is suspected, I prescribe Holter ECG monitoring. If the results are questionable, I use provocative tests that cause spasm of the coronary arteries - ergometrine (intravenous administration of the vasoconstrictor drug Ergometrine), cold (lowering the hand to the middle of the forearm for 5 minutes in water at a temperature of + 4 degrees), hyperventilation (the patient breathes intensely and deeply for 3 -4 minutes). If the result is positive, pain appears along with ST segment elevation on the ECG.

Often the listed changes in the ECG are accompanied by heart rhythm disturbances - supraventricular tachycardia, atrial fibrillation, slowing of atrioventricular conduction, bundle branch block, etc.

Echocardiography (Echo-CG, ultrasound of the heart) allows me to evaluate morphological changes - myocardial contractility, the degree of hypertrophy and expansion of the chambers, check the structure of the valves, the presence of aneurysms and intracardiac thrombi.

Myocardial scintigraphy is a study of the state of blood flow in the myocardium using a radioactive drug (thallium-201 or technetium-99-m). I use this method in patients with stable angina who have severe heart rhythm disturbances that make it impossible to see changes in the ST segment.

The essence of scintigraphy: the patient is injected with a drug, he begins to perform physical activity on a treadmill or bicycle ergometer, and images are obtained using a special gamma tomograph. Areas of impaired blood circulation (ischemia) have a faint glow.

Coronary angiography is the gold standard for diagnosing coronary artery disease, allowing to assess the patency of the coronary arteries. It can also be used to determine whether a given patient needs surgical intervention or whether drug therapy alone can be used.

Beta blockers

Beta blockers

– reduce the heart rate (pulse), thereby reducing the work performed by the heart and the need of the heart muscle (myocardium) for oxygen, improving blood supply to the heart, reducing the number of
angina attacks
and increasing exercise tolerance.
Beta blockers prevent and treat abnormal heart rhythms (arrhythmias). This is especially important after a myocardial infarction
, when the arrhythmia often becomes life-threatening.
Regular use of beta blockers can prevent the death of patients who have had a heart attack by up to 40% (in every 40 people out of 100!). Therefore, they are recommended to be prescribed to all patients after a heart attack
, in the absence of contraindications.
Beta blockers normalize blood pressure. In most patients, angina is combined with arterial hypertension
, in this case, taking a beta blocker “kills two birds with one stone” -
we treat hypertension and angina
at the same time. Some beta blockers have been shown to prevent the development of heart failure. These include metaprolol succinate (BetalokZOK), bisoprolol (Concor), nebivalol (Nebilet), carvedilol (Dilatrend). This effect, just like all of the above, is possible only with regular long-term use of the drug.

How to take beta blockers

Take a beta blocker daily, in the morning (long-acting drugs, about 24 hours) or twice a day (morning and evening). The dose of the beta blocker is selected individually. The dose is considered effective if your resting heart rate is 50-60 beats per minute while taking the drug. In this case, all the therapeutic effects of the drug are manifested. You should not suddenly stop taking the beta blocker - in the first days, your pulse may reflexively increase sharply and your health will worsen. In those patients with angina

who take a beta blocker to maintain the correct rhythm and prevent arrhythmia, after discontinuation, interruptions in heart function may resume. Undesirable effects of beta blockers are characteristic mainly of non-cardioselective drugs (for example, decreased potency), and in modern highly cardioselective drugs they occur rarely, usually with increasing doses. It is undesirable to prescribe beta blockers to patients with bronchial asthma and chronic obstructive pulmonary disease COPD), atherosclerotic lesions of the arteries of the lower extremities (atherosclerosis obliterans).

How and with what they are treated

Angina pectoris requires competent and comprehensive treatment, including the use of medications, surgical interventions, and lifestyle correction.

I treat angina pectoris using the following medications:

• beta-blockers (Bisoprolol, Metoprolol) – reduce the myocardial oxygen demand and improve its blood circulation;
• calcium channel blockers (Diltiazem, Verapamil) - have a similar mechanism of action. I resort to them in case of contraindications to beta blockers (for example, with severe bronchial asthma);
• antiplatelet agents (Acetylsalicylic acid, Clopidogrel) – prevent the “gluing” of platelets, thereby preventing the formation of blood clots;
• anticoagulants (unfractionated, low molecular weight heparin) – also suppress the process of blood clot formation by affecting plasma coagulation factors;

• statins (Atorvastatin, Rosuvastatin) - help slow down the growth of atherosclerotic plaques by lowering cholesterol levels in the blood;
• nitrates (Nitroglycerin, Isosorbide dinitrate) and dihydropyridine calcium channel blockers (Amlodipine, Nifedipine) - cause dilation of the coronary arteries, which increases blood flow to the myocardium;

An important point is that nitrate tablets should not be swallowed, but placed under the tongue.

In the hospital

It is almost always worth starting treatment for angina in a hospital, especially for unstable forms. When a person is admitted to the hospital, I use the following drug therapy regimens depending on the type of angina:

1. Stable – beta-blocker, antiplatelet agent, statin. Nitrates only during an attack, taking into account that the break between doses should be at least 10-12 hours. With more frequent use, the effectiveness of nitrates decreases several times.
2. Unstable - beta-blocker, necessarily 2 antiplatelet drugs, an anticoagulant, a narcotic painkiller, a statin.
3. Vasospastic - dihydropyridine calcium channel blocker, nitrate, antiplatelet agent.

Cardiac syndrome X deserves special attention. Standard therapy is effective in only half of patients with this diagnosis. To the treatment of these patients, it is necessary to add antidepressants, sedatives, hormone replacement therapy with estrogen, and aminophylline. Psychotherapy can also help.

If a patient with stable or unstable angina has severe atherosclerotic damage to the coronary vessels, as well as a high cardiovascular risk (old age, diabetes mellitus, rapid progression of the disease, increased cholesterol and blood pressure, etc.), surgical treatment is indicated for him. .

There are two types of operations:

• coronary artery bypass grafting (CABG);
• percutaneous transluminal balloon coronary angioplasty (PTCA), or stenting.

With CABG, a fistula (shunt) is created between the internal mammary and coronary arteries. This method is used in cases of multiple damage to the heart vessels by atherosclerosis.

During PTCA, a metal stent (a spring-shaped frame) is inserted into the artery, which widens the lumen of the vessel. Drug coatings are sometimes used. The rationale for choosing PTCA is a hemodynamically significant decrease in patency (less than 50%) in one artery. Often, stenting is performed in parallel with coronary angiography.

Statins

Statins – antiatherosclerotic drugs

, reduce the level of “bad” cholesterol in the blood (total cholesterol, LDL, triglycerides), increase the level of “good” cholesterol (HDL). With long-term use of the drug in a dose that allows you to control cholesterol at the target level, they can stop the growth of atherosclerotic plaques and even reduce their size. Target cholesterol levels depend on the prevalence of atherosclerosis in the body and associated diseases (for example, diabetes). Ask your doctor what your target levels should be and monitor the effectiveness of treatment (blood tests for cholesterol and lipids) at least 4 times a year. There is no habituation to statins or development of dependence; treatment with statins should be carried out continuously. If you stop taking it on your own, then within one month after stopping the drug, your blood lipid levels return to baseline.

Statins

can reduce the risk of
myocardial infarction
and stroke by up to 30-40% (in every 30-40 people out of 100), and this effect is more pronounced in diabetics!
The fact that statins save lives became known after several large studies, which involved thousands and tens of thousands of patients with angina pectoris
, diabetes mellitus, and peripheral atherosclerosis.
Today, statins are recommended for treatment not only for patients with angina
, but also for people without coronary artery disease, with several risk factors, for the prevention of atherosclerosis, heart attack and stroke.
Four drugs in this group are registered in Russia: simvastatin (Zocor), rosuvastatin (Crestor), atorvastatin (Liprimar) and fluvastatin (Leskol).

How to take statins

Take statins in the evening (before bedtime). There are medications that can be taken at any time of the day. Nausea and stool disturbances are possible. The use of statins is not recommended for persons with active liver disease or during pregnancy and breastfeeding. A very rare side effect is muscle pain. If you start taking the drug and notice soreness in all the muscles of your body, be sure to tell your doctor to avoid unwanted complications. If you do not tolerate statins well or taking the maximum therapeutic dose does not allow you to control lipid levels, then it is possible to reduce the dose and add a cholesterol absorption inhibitor, ezetimibe. Your doctor may also recommend the use of other lipid-lowering drugs for treatment: fibrates, delayed-release nicotinic acid.

Clinical case

I recently saw a classic case of angina. A 62-year-old man was delivered to the emergency cardiology department by an ambulance team. According to the doctor, the patient, in a state of complete rest, developed severe squeezing pain in the heart area, radiating to the left arm. Taking Nitroglycerin did not relieve the pain. The duration of the attack is about 30 minutes. An ambulance was called. The medical staff took an ECG - a decrease in the ST segment was recorded, tablets of Acetylsalicylic acid, Clopidogrel and Metoprolol were given, and low molecular weight heparin was administered intravenously. Upon admission to the hospital, blood was taken for cardiac enzymes. Since the patient was experiencing unbearable pain, I prescribed him a narcotic painkiller - Promedol. Coronary angiography was performed. Conclusion: stenosis of the right coronary artery – 75%. PCI with stenting was performed. Cardiac enzyme results ruled out myocardial infarction. Clinical diagnosis: “IHD. Unstable angina IIIB according to Braunwald." For continuous use, I was prescribed Acetylsalicylic acid, Clopidogrel, Metoprolol, Rosuvastatin and Isosorbide mononitrate for pain.

Doctor's advice

In addition to the generally accepted lifestyle interventions described above, I strongly encourage my patients to monitor their blood pressure and take appropriate medications regularly.

If a person suffers from diabetes, he should regularly check his blood glucose levels and periodically take a glycated hemoglobin test. This is important, since diabetes can worsen the course of angina several times and lead to complications.

Also, if you cannot eat fish often, you can take fish oil in the form of dietary supplements. They are available in any pharmacy. To argue for the benefits of fish oil, I would like to give the example of Japan, a country where heart disease rates are extremely low, and fish as a food product occupies the top positions.

Clinical case

I would like to provide an example from personal experience.
A 52-year-old man visited his local physician for an outpatient appointment with complaints of pressing pain in the heart area, which occurs when climbing the stairs to the 3rd floor and goes away a few minutes after resting. I began to notice the appearance of these pains about a month ago. Suffering from type 2 diabetes mellitus and hypertension. She takes Metformin 1000 mg 2 times a day and Lisinopril 10 mg 1 time a day. The therapist referred him to a cardiologist, who prescribed an ECG and VEM (veloergometry). At rest, when deciphering the ECG, there were no changes. When performing a VEM, an ECG revealed ST segment depression of 2 mm. The patient was sent to the cardiology hospital for further examination with a diagnosis of coronary artery disease, angina pectoris FC 2. Coronary angiography was performed, which revealed 70% stenosis of the right coronary artery. The damage to the remaining vessels was not critical, so the decision was made to install a stent. Drug therapy was also prescribed (Acetylsalicylic acid, Rosuvastatin, Bisoprolol). The patient noted a significant improvement in his condition in the form of cessation of pain attacks. Upon discharge, recommendations for lifestyle modifications were given.

In conclusion, I would like to note that angina pectoris is a serious disease that requires due attention from both the doctor and the patient. Ignoring attacks of pain can lead to an unfavorable prognosis in the form of myocardial infarction, disability and death. However, timely diagnosis and proper treatment can improve the quality and increase the life expectancy of a person.

After discharge

Basically, drug treatment does not change after discharge from the hospital. The patient must take most medications for life. You can read more about medication regimens and dosages here. Some drugs are not indicated for long-term use by the patient, for example, anticoagulants, except when they are necessary for the treatment of concomitant diseases.

If the patient has undergone PCI with stenting, he must take 2 antiplatelet drugs (Acetylsalicylic acid and Clopidogrel) for at least 1 year. Next, he needs to switch to a constant intake of 1 medication - if he does not have a gastric ulcer or duodenal ulcer, then Acetylsalicylic acid, if he does, then Clopidogrel.

To prevent the development of ulcers, I recommend that my patients add drugs that reduce the formation of hydrochloric acid in the stomach - Omeprazole, Pantoprazole.

Angiotensin-converting enzyme inhibitors (ACEIs)

Angiotensin-converting enzyme inhibitors (ACEIs)

–
for angina pectoris,
they are prescribed to prevent the development of heart failure.
Therefore, drug doses are usually lower than for the treatment of hypertension. If after a MI you develop symptoms of heart failure or doctors identify impaired LV function, adding an ACE inhibitor to your therapy will significantly reduce the risk of death and the likelihood of a recurrent MI. The effect of drugs such as ramipril, trandolapril, zofenopril, enalapril has been proven. If these drugs are poorly tolerated, replacement with angiotensin receptor antagonists is possible. ACE inhibitors can be prescribed for angina pectoris without a history of heart attack
- their ability to slow the progression of atherosclerosis has been proven. The effect of the drugs ramipril and perindopril has been proven.

Expert advice: what you can and cannot do for angina pectoris

I always tell my patients: in order for the treatment to be successful and maintain its effect, you need to follow certain rules and adhere to the following recommendations.

• bad habits - you definitely need to quit smoking, because... smoking is one of the main factors in the progression of atherosclerosis. It is also necessary to limit the consumption of alcoholic beverages to 2-3 glasses of wine per week;
• nutrition - it is advisable to reduce in your diet foods high in animal (saturated) fatty acids (lard, fatty fried meat, smoked meats, butter, etc.), while increasing the amount of foods rich in unsaturated (omega-3.6) fatty acids (fish, vegetables, vegetable oil). Also, the patient’s daily menu should contain fruits, nuts, cereals, and grains. Patients with diabetes need to significantly reduce the percentage of easily digestible carbohydrates (sweets, chocolate, pasta, pastries, cakes, buns, etc.). More complete information about nutrition for angina pectoris here;
• blood pressure control - it is achieved by daily measurement of blood pressure, limiting salt to 3 g per day, constantly taking medications to lower it in compliance with the prescribed dosages and frequency;
• combating obesity - this is facilitated by diet and regular exercise (running, cycling, swimming). For severe angina, morning exercises and walking at least 3 km per day are allowed;
• sex - contrary to all myths, sex with angina is allowed, but with certain nuances. You can find out more about them here.

Smoking, intense exercise (weightlifting, extreme sports), and unauthorized discontinuation of prescribed medications are strictly prohibited. All this can lead to a sharp deterioration in the patient’s condition, increasing the risk of myocardial infarction and death.

Antiplatelet agents

Antiaggregates help prevent the formation of blood clots (thrombi), reduce the aggregation (sticking together) of platelets - blood cells that are responsible for the formation of a blood clot. The list of antiplatelet agents includes: aspirin, cardiomagnyl, thienopyridines.

Aspirin (acetylsalicylic acid)

Aspirin (acetylsalicylic acid)

– the main antiplatelet agent, it is prescribed to all patients suffering from angina pectoris (with the exception of those who cannot tolerate it, for example, allergy sufferers with the “aspirin triad”). The dose of aspirin is 75-150 mg daily. Taken once, every 20-30 minutes. after meal. Typically in the afternoon. Pay attention to the low dose! A typical aspirin tablet contains 500 mg, a dose that has been taken as an analgesic and antipyretic for over 100 years! For angina pectoris, no more than 1/4 tablet is recommended. This dose effectively prevents thrombosis and is quite safe for the stomach. When regularly taking higher doses of aspirin (acetylsalicylic acid), there is a risk of developing erosions and stomach ulcers. Since patients with angina pectoris require constant use of aspirin as treatment, special, safer forms for long-term use have been developed.

Cardiomagnyl (aspirin + magnesium hydroxide)
Cardiomagnyl (aspirin + magnesium hydroxide)
75 and 150 mg. Magnesium hydroxide, which is part of the tablet, stimulates the formation of special protective substances in the stomach wall of a patient with angina pectoris that prevent the formation of ulcers and erosions.

Enteric-coated aspirin (AspirinCardio 100 mg, ThromboAss 50 and 100 mg, CardiASK 50 mg, etc.)

. The special coating does not allow the tablet to dissolve in the stomach; absorption of aspirin occurs in the intestines. Important: these tablets must be taken whole, you cannot break them or chew them (otherwise you will damage the shell and the protective effect will disappear)!

Thienopyridines (clopidogrel, prasugrel, ticlopidine)

Thienopyridines (clopidogrel, prasugrel, ticlopidine)

– have a very pronounced antiplatelet effect, hundreds of times stronger than aspirin.
The prescription of these drugs (usually together with aspirin) is necessary in cases where the risk of thrombosis is very high: unstable angina
,
acute coronary syndrome
(“pre-infarction conditions”),
acute myocardial infarction
and cardiac surgery (
stenting
,
coronary artery bypass grafting
and etc.). Thienopyridines are also prescribed as a treatment for those patients who cannot take aspirin due to intolerance or contraindications.

Important:

Tell your doctor if you have previously had a stomach ulcer, duodenal ulcer (DU) or erosive gastritis, as well as unstable blood pressure with frequent crises, rises above 160-170/100 mm Hg. Art. This information will help your doctor make your antiplatelet treatment safe. It has been proven that regular use of antiplatelet drugs can reduce the incidence of myocardial infarction, strokes and death in patients with angina pectoris by up to 23% (in every 23 people out of 100)! After coronary angioplasty and stenting operations, doctors recommend taking aspirin and clopidogrel together for a certain period of time (from a month to several years).

What can the disease be confused with?

As for diseases not related to the cardiovascular system, based on the symptoms and signs, angina pectoris can be mistaken for:

• osteochondrosis of the cervical or thoracic spine;
• vegetative-vascular dystonia;
• gastrointestinal diseases (diaphragmatic hiatal hernia);
• pleurisy, pulmonary embolism;
• pinched nerves.

Usually this disease is confused with the onset of myocardial infarction. The signs are really very similar. The main difference is that an attack of angina is relieved by taking nitroglycerin. In case of a heart attack, the medicine does not work or relieves pain only slightly and temporarily.

Which doctor should I contact?

Any alarming signs characterizing pathological processes in the heart are a reason to immediately go to an appointment with a cardiologist. Self-medication, the use of traditional methods or advice from doctors that other patients have received is unacceptable. Each clinical case of angina is unique - it is provoked by various factors and has varying degrees of severity, therefore, without individual diagnosis and a treatment program developed specifically for you, it will not be possible to overcome the disease.

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Where can I get diagnosed and treated?

Rest assured that your heart is not in danger! If the first symptoms and signs of angina appear, consult a qualified healthcare provider. Cardiologists at the CBCP Center for Circulatory Pathology are ready to help you. The clinic will offer professional consultation and modern types of diagnostics, through which the doctor will receive objective, detailed and accurate information about the disease.

If you discover serious violations, do not despair! The level of medicine at CBCP makes it possible to effectively treat complex cardiovascular diseases using medicinal and non-surgical methods.

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