Hunstable angina (NS) - acute process of myocardial ischemia, the severity and duration of which are insufficient for the development of myocardial necrosis. There are usually no ST elevations on the ECG. There is no release of biomarkers of myocardial necrosis into the bloodstream in quantities sufficient for the diagnosis of myocardial infarction.

Unstable angina (NS) reflects such a course of coronary artery disease, in which, as a result of an exacerbation of the pathological process, the risk of myocardial infarction or sudden death is significantly higher than with stable angina. Working classification of coronary artery disease (HC only)

• 2.2. Unstable angina:

2.2.1. New-onset angina pectoris (IRS). *

2.2.2. Progressive angina pectoris (PS).

2.2.3. Early postinfarction or postoperative angina pectoris.

2.3. Spontaneous (vasospastic, variant, Prinzmetal) angina pectoris. **

3. Painless myocardial ischemia. **

Note: * sometimes the first-onset angina pectoris has a stable course from the very beginning; ** some cases of painless myocardial ischemia, as well as severe attacks of spontaneous angina pectoris, can be attributed to unstable angina pectoris.

By now, it has become obvious that the causes of the progressive course of coronary artery disease are due to changes in atherosclerotic plaque, endothelium and platelets. The most important mechanism for the development of acute coronary insufficiency (in particular, NA) is considered to be rupture of an atherosclerotic plaque in the coronary artery with the subsequent formation of a thrombus and an increase in the tendency to coronary spasm. At pathomorphological studies in 95% of suddenly died patients with coronary artery disease, tears of atherosclerotic plaques with the imposition of thrombotic masses are found. Thus, the pathomorphological basis of NS is "complicated thrombotic atherosclerotic plaque". The risk of rupture is largely due not to the size of the plaque, but to its composition. Plaques with a loose core containing a large amount of lipids and a thin surface layer are more often ruptured. They usually have less collagen and smooth muscle cells and more macrophages.

Factors contributing to damage to atherosclerotic plaque can be divided into external and internal. The former include: arterial hypertension, increased sympathoadrenal activity, vasoconstriction, the presence of a pressure gradient before and after stenosis, which, along with periods of extension-compression at the sites of branching and bending of vessels, leads to a weakening of the plaque structure, high levels of LDL, triglycerides, fibrinogen molecules, fibronectin , the von Willibrand factor. Inflammation is considered to be one of the factors of AB destabilization lately. Internal factors of atherosclerotic plaque rupture include the predominance of the lipid core, a decrease in the amount of SMC and collagen synthesis, and the activation of macrophages. In some cases, a blood clot forms on the surface, i.e. is located above the break (crack, defect) of the plaque. More often, it penetrates into the plaque, leading to a rapid increase in its size.

NS is a heterogeneous group of ischemic syndromes, which, in terms of their clinical manifestations and prognostic value, occupy an intermediate place between the main clinical and morphological forms of ischemic heart disease - stable exertional angina and myocardial infarction. Recently, the term "acute coronary syndrome" has appeared in the foreign scientific and practical literature on cardiology, which includes unstable angina pectoris and myocardial infarction without a Q wave (non-Q myocardial infarction). The term acute coronary syndrome (ACS) was introduced into clinical practice when it became clear that the question of the use of some active methods of treatment, in particular thrombolytic therapy, should be resolved before the final diagnosis is established - the presence or absence of large-focal myocardial infarction.

At the first contact of a doctor with a patient, if there is a suspicion of ACS, according to clinical and ECG signs, it can be attributed to one of its two main forms.

Acute coronary syndrome with ST segment elevation and without ST segment elevation.

Acute coronary syndrome without ST-segment elevations. Patients with chest pain and ECG abnormalities suggestive of acute myocardial ischemia, but no ST-segment elevations. These patients may have persistent or transient ST depression, inversion, flattening, or pseudo-normalization of the T wave. The ECG on admission is also normal. The management strategy for such patients is to eliminate ischemia and symptoms, follow-up with repeated (serial) registration of electrocardiograms and determination of markers of myocardial necrosis (cardiac troponins and / or creatine phosphokinase MV-KFK). In the treatment of such patients, thrombolytic agents are not effective and are not used. Therapeutic tactics depend on the degree of risk (severity of the condition) of the patient.

The classification approaches proposed by E. Braunwald (1989) seem to be of fundamental importance. Time intervals of diagnostic significance remain ultimately undefined. Thus, the duration of the history of the onset or progression of IHD symptoms, regarded as manifestations of NA, according to foreign cardiologists, corresponds to two months, and according to the traditional views of domestic cardiologists - one month.

Classification of unstable angina pectoris (C. W. Hamm, E. Braunwald Circulation 2000; 102: 118.)

A - Develops in the presence of extracardiac factors that increase myocardial ischemia. Secondary NS B - Develops without extracardiac factors. Primary NS C - Occurs within 2 weeks after myocardial infarction. Postinfarction NS I - First appearance of severe angina pectoris, progressive angina pectoris; without rest angina II - Angina at rest in the previous month, but not in the next 48 hours; (rest angina, subacute) III - Rest angina pectoris in the previous 48 hours; (rest angina, acute) IIIB IIIB - Troponin - IIIB - Troponin +

Forecast.

NS is accompanied by an increased risk of acute myocardial infarction, which develops in the next 1-2 weeks in 5-10-20% of patients. 11% - undergo acute myocardial infarction within the first year after NS. Hospital mortality - 1.5%; mortality within 1 year from the moment of the onset of NS - 8-9%. The five-year mortality rate of those who have had HC is more than 30%. With vasospastic angina within 6 months after the first attack of angina pectoris, 20% of patients develop acute myocardial infarction and 10% die.

According to the clinic and prognosis, unstable angina is an intermediate state between stable angina and the onset of myocardial infarction. It is she who is the most dangerous period of coronary artery disease (coronary heart disease), since in this case myocardial ischemia is progressive. The symptoms of the disease are quite specific.

In cardiology, the concept of "unstable angina" combines conditions that are characterized by a violation of the coronary arteries of the heart and attacks of cardialgia (pain in the heart):

• first time diagnosed exertional angina;
• progression of exertional angina;
• resting angina for the first time.

Causes of the disease

The cause of unstable angina in coronary artery disease is the rupture of fibrous plaque previously formed in the lumen of the coronary artery. This leads to the formation of a blood clot, which prevents the full supply of blood to the heart myocardium. The result is cardiac muscle hypoxia. Damage to the integrity of the plaque can be caused by:

• excess fat deposits directly inside the plaque itself;
• inflammation;
• lack of collagen;
• deviations related to hemodynamics.

The development of unstable angina pectoris can be caused by:

Unstable angina is provoked by the following diseases and conditions of the body:

• diabetes;
• genetic predisposition, if relatives have an IHD;
• stable increase in blood pressure;
• changes in the quality of blood and its thickening;
• being overweight;
• high / low blood cholesterol;
• sedentary lifestyle;
• the presence of male gender characteristics in women;
• nicotine addiction;
• old age.

Advice! Treatment of this heart pathology is always carried out stationary.

Forms of unstable angina

Doctors carry out a kind of internal gradation of this cardiac pathology:

• First-onset angina. It is characterized by recurrent retrosternal pressing pains. They can give to the left hand, neck and lower jaw. Sometimes in the epigastric region.
• Progressive angina pectoris. This pathological condition is characterized by an increase in the duration of an attack in time, as well as an increase in its pain. Cardialgia is formed not only with increased physical activity, but also with lower loads. Sometimes alone. It is accompanied by shortness of breath and lack of air.
• Postinfarction and postoperative angina pectoris.

The Braunwald classification can also be used. In this case, a class is assigned to unstable angina. And the higher it is, the more likely the formation of any complications:

• Grade 1 - angina pectoris, diagnosed for the first time, or an increase in an existing heart pathology;
• Grade 2 - rest angina, which appeared in the last month;
• Grade 3 - rest angina, which appeared in the last two days.

Symptoms of unstable angina

Typical unstable angina pectoris manifests itself with symptoms characteristic of coronary heart disease. And the increase in symptoms indicates the progression of the disease. The main symptoms are:

Advice! Symptoms of coronary artery disease, bothering a person for a long time, can cause the development of a heart attack.

Features of the course of unstable angina

Unstable angina is manifested as a clinical symptom of coronary artery disease - pain in the heart. The duration and intensity of the onset cardialgia increases each time.

The expansion of the area of \u200b\u200bspread of pain is almost always noted, and the cardialgia itself begins to acquire an undulating character: periodically subsiding and intensifying again. Unstable angina differs from the stable variant in that to stop the attack, it is necessary to take an increased dose of the prescribed drugs.

Quite often, unstable angina occurs as a result of increased physical or mental stress. As the pathology of the heart progresses, attacks of coronary heart disease can occur against the background of even minimal psychoemotional and physical stress. Cardialgia of ischemic heart disease in various diseases, for example, flu, ARVI, etc. is not excluded.

Diagnosis of pathology

Diagnosis of unstable angina pectoris is carried out in two directions:

• oral questioning and medical examination;
• laboratory and instrumental research.

First of all, an oral survey is carried out, during which the doctor receives the following information:

A medical examination of the chest is certainly carried out, including:

• listening;
• tapping;
• palpation of the heart area (this procedure helps in some cases to reveal an increase in the size of the left ventricle of the organ).

Laboratory and instrumental research

In addition to conducting an oral questioning and examination, the doctor prescribes the following tests:

• General blood tests. The analysis gives an idea of \u200b\u200bthe inflammation taking place in the body. In this case, an increase in the number of leukocytes and an increase in ESR are recorded.
• Urine examination. To identify concomitant diseases.
• Blood biochemistry. Here the main focus is on cholesterol levels, fractions, blood sugar. This makes it possible to assess the risk of developing vascular atherosclerosis.
• Research of blood enzymes.

It is also necessary to conduct certain instrumental studies. It:

• ECG procedure. Allows you to track the work of the heart. With unstable angina pectoris, changes in the ST segment and T wave are recorded.
• Echocardiography (EchoECG). Ultrasound examination of the heart. Allows you to track all possible changes in its work, as well as determine the presence of myocardial ischemia. But sometimes even the full rate of ultrasound of the heart does not exclude the presence of unstable angina.
• Daily Holter study. Here, an electrocardiogram is taken within a day. The work of the heart is recorded with a special device (Holter monitor). Such a study allows you to identify the existing ischemia, the reasons for its occurrence, deviations in the heart rhythm, etc.
• Stress echocardiography. The technique is based on a combination of physical activity and simultaneous EchoECG. The indicators of the heart are recorded in three positions: at rest, at the peak of the load, during rest. The study will reveal the damaged areas of the myocardium.
• Myocardial scintigraphy. Radioactive drugs are injected into the human body, which makes it possible to obtain an image of the walls and cavities of the heart.
• Coronary angiography. X-ray examination of the state of the coronary bed. The procedure can be ordered when discussing surgical treatment. It makes it possible to identify the existing blood clots and areas of vasoconstriction.

Treatment of unstable angina

Patients diagnosed with unstable angina pectoris should receive treatment in a hospital. In this case, an emergency hospitalization is prescribed.

Drug-free treatment

The patient is assigned a sharp restriction of freedom of movement - the strictest bed rest. Its observance is necessary until the moment of restoration of stable blood circulation in the coronary vessels of the heart.

Drug therapy

Treatment of unstable angina of the heart is aimed primarily at eliminating attacks of cardialgia, as well as preventing the development of such a serious condition as myocardial infarction. Drug therapy for unstable angina pectoris is represented by the following categories of drugs:

• For relief of chest pain. Here drugs from the group of nitrates are prescribed for admission. They do an excellent job with heart pain, but do not affect heart rate and blood pressure readings.
• Medicines that can reduce myocardial oxygen demand. These are beta-blockers - funds help to expand the lumen of blood vessels, slow down the heart rate and eliminate pain in the heart. The most commonly used calcium antagonists.
• Blood thinning drugs. Here, antiplatelet agents (drugs that reduce the sticking ability of platelets) or direct anticoagulants (drugs inhibit the blood clotting ability, which prevents the formation of blood clots) can be prescribed.

Advice! Quite often in the course of treatment, the neuroleptanalgesia technique is used. In this case, pain relievers are administered intravenously to the patient. At the same time, the person remains fully conscious, but temporarily loses the ability to experience any emotions.

In about 80% of all cases, drug treatment of pathology allows you to obtain the necessary therapeutic effect - to stabilize the state of blood flow in the coronary arteries. In the absence of positive dynamics, the patient is prescribed surgical treatment.

Surgery

In this case, unstable angina pectoris should be treated using the following methods:

1. Angioplasty of the damaged coronary vessel with subsequent stenting. The essence of the method lies in the introduction of a metal tube - a stent into the narrowed lumen of the damaged vessel. It is he who holds the vascular walls, restoring the transmitting function of the vessel to the required norm.
2. Coronary artery bypass grafting. This technique is used in two cases: when the main coronary artery is damaged, or when the lesion has affected all coronary vessels. Here, a new vascular bed is created artificially. And the blood is already delivered through it to the myocardium site.

Possible consequences and complications

If you do not start treatment on time, then this condition can cause the following complications:

Prevention of unstable angina

Preventive measures for unstable angina pectoris are as follows:

• In a complete cessation of smoking and the use of alcoholic beverages.
• Elimination of high psychoemotional tension.
• Maintaining your weight within normal limits.
• Daily physical activity.
• Close monitoring of blood pressure indicators.
• Nutrition should be balanced.
• It is necessary to control blood cholesterol levels.

Unstable angina is a serious condition that requires immediate medical attention. And the characteristic symptoms that have appeared are a clear reason for contacting a specialist doctor. Since only adequate and timely treatment can save a person's life.

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• Analysis of the anamnesis of the disease and complaints - when (how long ago) for the first time and what kind of complaints appeared (pain in the heart, shortness of breath, weakness), what measures the patient took and with what results, whether he went to the doctor, with what the patient associates the occurrence of these symptoms.
• Life history analysis - aimed at identifying risk factors for the development of angina pectoris (for example, tobacco use, frequent emotional stress), dietary addictions, lifestyle are clarified.
• Family history analysis - whether relatives have cardiovascular diseases, sudden deaths.
• Medical examination - listening, tapping and palpating the region of the heart - you can detect signs of hypertrophy (increase in mass and size) of the left ventricle, left ventricular failure and atherosclerosis of various vascular basins.
• Complete blood count - allows you to detect signs of inflammation in the body (an increase in the level of leukocytes (white blood cells), an increase in the level of ESR (erythrocyte sedimentation rate (red blood cells), a nonspecific sign of inflammation)).
• General urine analysis - allows you to detect concomitant pathology.
• Biochemical blood test - it is important to determine the level of cholesterol (a fat-like substance, which is a "building material" for body cells), fractions, blood sugar to assess the risk associated with vascular atherosclerosis.
• Study of specific enzymes in the blood. These intracellular protein enzymes, when the heart cells are destroyed, are released into the bloodstream and prevent myocardial infarction.
• Electrocardiography (ECG) - a method of recording the electrical activity of the heart on paper - changes in the ST segment (a segment of the ECG curve that corresponds to the period of the cardiac cycle when both ventricles of the heart are completely covered with excitation) and the T wave (reflects the repolarization (recovery) cycle of the ventricles of the heart muscle) are detected ...
• Echocardiography (EchoECG) - a method of ultrasound examination of the heart, allows you to assess the structure and size of the working heart, study the intracardiac blood flows, the state of the valves, identify possible violations of the contractility of the heart muscle and determine a number of specific signs of myocardial ischemia. Normal echoECG does not exclude the presence of unstable angina.
• Holter daily monitoring of an electrocardiogram (ECG) - recording an electrocardiogram for 24-72 hours, the study reveals myocardial ischemia, the conditions for its occurrence, duration, heart rhythm disturbances are determined, which can aggravate the course of the disease. For the study, a portable device (Holter monitor) is used, fixed on the shoulder or belt, which allows you to periodically identify the patient and take readings, as well as a self-observation diary, in which the patient notes his actions and changes in health by the clock.
• Stress echocardiography - the method is a combination of physical activity with echocardiographic (EchoCG) examination, which allows to identify the zones of impaired contractility of the heart muscle caused by physical activity. Comparison of the ultrasound scan indicators at rest, at the height of the load and during rest. These data are compared with changes in the cardiogram and the existing symptoms identified at maximum exercise. In the acute period, it is not carried out, since myocardial infarction may occur, with successful treatment, it is carried out for 7-10 days.
• Myocardial scintigraphy is a method of functional visualization of the walls and cavities of the heart, which consists in introducing radioactive drugs into the body and obtaining an image by determining the radiation emitted by them.
• Coronary angiography - a radiopaque method for studying the state of the coronary bed - is indicated when discussing the issue of surgical treatment of unstable angina pectoris or in patients with prognostically unfavorable signs of the course of the disease. The study allows you to identify blood clots (blockages) and vasoconstriction.
• Therapist's consultation is also possible.

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What is the difference between stable and unstable angina?

As you know, the cause of ischemic heart disease, including angina pectoris, is atherosclerosis. This is the name of a disease in which accumulations of cholesterol and other harmful lipids begin to be deposited in the walls of the arteries. Atherosclerosis affects all arteries, but the vessels of the heart (coronary arteries), for a number of reasons, often suffer from it faster and stronger than others.

Due to the growth of cholesterol plaques, "protruding" into the vessels, their lumen gradually decreases. This disrupts blood flow through them. As a rule, when a person is in a calm state, the disorder of the coronary circulation does not manifest itself in any way. But the moment the patient is exposed to physical or other stress, the situation changes. The heart begins to work harder and needs to increase blood flow. Vessels narrowed by atherosclerosis with sealed walls cannot satisfy this need. The myocardium begins to experience oxygen starvation, under-oxidized metabolic products are formed in it, the metabolism of sodium and potassium is disrupted, and this leads to irritation of the sensitive nerve endings of the heart. So there is an attack of angina pectoris.

With a stable course, angina pectoris "behaves" predictably. Attacks occur whenever the load on the heart increases and disappears at rest, as well as when taking nitroglycerin drugs, which dilate the coronary arteries.

Unlike stable angina, unstable angina manifests itself differently. This disease is based on a sharp destabilization of the coronary blood flow. In more understandable language, the lumen of the coronary vessels narrows even more in a short time than before, which causes a change in the usual course of the disease, its deterioration. As a rule, this happens under the influence of some kind of "irritants" - factors that provoke an exacerbation of IHD. This can be an increase in blood pressure, rhythm disturbances, too intense physical activity, discontinuation of conventional drugs for the treatment of angina pectoris, even a change in climate.

Unstable angina is a dangerous condition that requires immediate hospital treatment. The fact is that it occupies an intermediate position between stable angina pectoris and acute myocardial infarction. Accordingly, in the absence of proper treatment, the risk of its transition to a heart attack is extremely high.

How does unstable angina appear?

Sometimes it is not easy to determine this disease, since unstable angina pectoris does not include any specific symptoms that accurately confirm its presence, but a whole group of rather heterogeneous symptoms. Sometimes in terms of symptoms it is practically indistinguishable from "ordinary" angina pectoris, sometimes it is very similar to myocardial infarction ... Let's discuss its possible manifestations in more detail.

So, the following situations belong to unstable angina.

1. Progressive exertional angina (up to 1 month after stable condition). This is a fairly common situation. A patient who previously had exertional angina suddenly begins to notice that his disease has changed its course in some way. The changes can be as follows:

• The attacks became longer or more frequent, or the effect of nitroglycerin decreased
• Changes in the nature, intensity of pain or its distribution (for example, earlier the patient had pressing chest pains that spread to the left shoulder, but became stronger, squeezing, "giving" to the shoulder and scapula)
• Attacks began to be provoked by lower loads.

1. An attack of prolonged angina pectoris with pain lasting more than 15 minutes, despite taking nitroglycerin.
2. New-onset angina pectoris: if the patient did not have chest pains before, but a month or less ago they first appeared, this suggests that the person has recently suddenly worsened coronary blood flow.
3. Early postinfarction angina. After a person has suffered a heart attack, he undergoes intensive treatment aimed at improving blood flow in the myocardium, accelerating its recovery and preventing a second heart attack. If, even against such a background, attacks of chest pain occur, this suggests that a blood clot is actively forming in the affected or other vessel, which may soon cause a second heart attack.
4. A person first had an attack of angina at rest.
5. Angina pectoris occurred in a patient who underwent coronary artery bypass grafting less than 3 months ago.

A case from practice.Patient S., 60 years old. He has been suffering from arterial hypertension since the age of 45, and at 51 he was diagnosed with exertional angina. The patient took all the necessary medications, tried to eat right, but due to the large amount of work (the director of the expanding network of gas stations) did not play sports and was often subjected to stress.

After celebrating his 60th birthday, the man decided that he had the right to rest, and went with the whole family on vacation to Spain. In an effort to "properly" rest, the patient enjoyed the local dishes (for a while he stopped following the diet), did not give up alcohol. Sometimes he forgot to take his medicine.

Against this background, he felt some deterioration in his condition: attacks of chest pains began to appear, which he had not had for a long time against the background of well-chosen treatment. However, he attributed this to climate change and the cost of "rest", so he continued his activity in the same mode.

Once, deciding once again to "take everything from life," he succumbed to the persuasion of his grandson and decided to go with him to the water park. It ended with the fact that the man was taken directly from the water park to the hospital: he had an attack of chest pains, he forgot to take nitroglycerin, so he could not stop the attack.

The patient was diagnosed with unstable angina. He spent the rest of his vacation in a hospital bed, and when he was discharged, it was time to return to Russia. Having returned, the man, at the insistence of his wife, turned to the Barvikha sanatorium for a cardiac rehabilitation program.

We adjusted the scheme of his drug therapy, planned the optimal exercise regimen for him, and performed physiotherapy. After a few days of staying in the sanatorium, the patient ceased to be upset that his rest was spoiled, and became firmly convinced that the stay in the sanatorium is a pleasant and useful continuation of the vacation. He followed all the necessary recommendations and was discharged after 2 weeks with significant improvement.

Sign up for rehabilitation ...

Diagnosis of unstable angina

So, unstable angina is suspected if his disease has changed in accordance with the above criteria. However, even doctors are not always able to "recognize" this disease at the first contact with a patient.

It often happens that a person suddenly has severe chest pain that lasts longer than 20 minutes and is almost unaffected by the effect of nitroglycerin. These symptoms are similar to those of a heart attack. However, after taking an ECG on the film, signs of ischemia are found, which speak of both angina pectoris and heart attack.

In this case, the patient is taken to the hospital with a diagnosis of Acute Coronary Syndrome, and there they carry out further diagnostics, which will determine what kind of disease the patient has. The patient will take blood and urine for general clinical tests, blood to determine markers of myocardial infarction. He will undergo electrocardiography and, if necessary, other tests that will help to make the correct diagnosis.

In other cases, when unstable angina is already evident by the symptoms, the patient is also hospitalized, examined and treated.

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The main differences between the unstable and stable type of pathology

So, we have already noticed that angina pectoris is, first of all, a kind of manifestation of ischemia (IHD) of the myocardium, caused by lesions of the coronary vessels. In this case, attacks of "angina pectoris" can be:

It is quite clear that unstable angina is considered a more dangerous variation of coronary artery disease threatening sudden development of complications.

The Braunwald classification of unstable angina is considered to be the most clearly describing the severity of the described ailment. According to this classification, unstable angina is divided into three classes:

Moreover, each of these classes can be represented by three degrees of severity of the attack:

• I degree. A seizure for the first time (class A, B, or C), without a problem at rest;
• II degree. Fixation of a seizure at rest (classes A, B or C) that occurs within one month, but not for the next two days;
• III degree. Detection of an attack of rest angina (class A, B or C), in the first two days.

Thus, the Braunwald classification identifies nine different options for describing angina attacks: AI, AII, AIII, BI, BII, BIII, CI, CII and CIII.

Causes of seizures

Most often, unstable angina is associated with the progression of a disease such as atherosclerosis of the coronary vascular bed.

The mechanism of development of pathology (IHD) is quite simple - the formed atherosclerotic plaque begins to gradually narrow the lumen of the coronary artery, thereby forming a lack of blood supply to a certain part of the myocardium.

Significant physical exertion, stress lead to the fact that the heart muscle needs more nutrition, while the narrowed coronary bed does not allow a sufficient amount of arterial blood to reach the myocardial cells - this is how an attack of angina pectoris occurs, of varying severity.

In addition, the causes of the development of coronary heart disease and the described attacks of "angina pectoris" doctors call:

We must not forget that doctors consider the elderly age of patients, male sex, bad habits, obesity, and an unhealthy lifestyle to be risk factors for the development of ischemia.

Symptoms of the problem

Unstable angina pectoris, depending on the severity, manifests itself in slightly different ways. In any case, this condition is a period of ischemia, bordering on a stable course of pathology and its sudden complication. Practitioners name the following most common symptoms of unstable angina:

In addition, it should be noted that unstable angina is characterized by an attack-like course and a certain duration of attacks (up to thirty minutes). Such attacks are usually controlled by taking a nitroglycerin tablet, although they can be complicated under unfavorable circumstances by more serious emergency conditions.

Diagnosing the problem

When making a diagnosis, practitioners usually use the following diagnostic criteria for pathology:

It is almost impossible to independently diagnose, with the definition of the type of ischemic heart disease, to recognize one or another attack of angina pectoris - to clearly establish the type of pathology, the patient must urgently consult a doctor!

Pathology treatment

First of all, it should be noted that the treatment of unstable angina pectoris cannot be carried out on an outpatient basis - patients with suspected development of this pathology are subject to urgent hospitalization in the intensive care unit.

Simultaneously with the prescribed treatment, doctors monitor the electrocardiography indicators, which allows them to notice the deterioration of the patient's condition in a timely manner.

The primary treatment of the problem is aimed at eliminating pain and preventing the recurrence of attacks. Typically, therapy begins with the appointment of nitroglycerin, aspirin in single doses, and then planned.

In addition, therapy for the attacks under consideration, depending on the causes provoking the development of ischemia, may include the appointment of the following drugs:

Most often, with the timely provision of medical care to patients with angina pectoris, their transfer from the intensive care unit to the cardiology ward is carried out on the second or third day, and discharge from the hospital after ten days of successful treatment. But, in cases where the treatment provided does not give the desired effect, physicians can urgently raise the issue of surgical intervention.

Surgical treatment of this pathology is a procedure of coronary artery bypass grafting, which allows you to quickly establish blood supply to the affected areas of the myocardium.

Predictions and lifestyle with such a pathology

Since the pathological condition in question is considered borderline, the prognosis for the course of unstable angina is usually unfavorable.

Unfortunately, the often recurrent pathology of this type often progresses rapidly and is complicated by myocardial infarction.

Nevertheless, medical practice knows many cases when, after stopping an attack of unstable angina pectoris, successful radical treatment of the problem, the patient's condition stabilized, and after a while the patients returned to their usual (albeit with some restrictions) life.

Summing up, it should be said that the lifestyle of a patient who once had an attack of unstable angina pectoris, in order to avoid relapses of pathology, should be significantly changed. All patients with coronary heart disease are advised to:

Unfortunately, the state of unstable angina does not allow patients to treat the problem of ischemia lightly.

It is important to understand that such attacks cannot be ignored, at the very first suspicions of the development of the described pathology, patients need to contact a doctor and not self-medicate!

Unstable angina is considered a pre-infarction condition, therefore, timely treatment should be carried out to help prevent formidable complications. A complete examination of the patient is mandatory, after which an individually selected therapy is prescribed.

Unstable angina pectoris (NS) refers to acute coronary syndrome (ACS), which also includes myocardial infarction with elevated ST levels and no ST elevation. Unstable angina is characterized by the formation of myocardial ischemia, which does not end with its necrosis (i.e., cardiac biomarkers of myocardial necrosis, such as creatine kinase isozyme, isopropylene, troponin, myoglobin, are absent in the bloodstream).

With unstable angina pectoris, emergency treatment is required, since the risk of developing myocardial infarction is high.

In the course of diagnosing NS, the first thing to do is to assess the clinical picture, after which instrumental and laboratory research methods are used. During the treatment of NS, efforts are aimed at restoring blood flow through the coronary vessels and preventing repeated cases of their blockage.

Video: What is angina pectoris?

Definition of unstable angina

The term "unstable angina" was first used in the early 1970s to define a condition referred to in earlier publications as pre-infarction angina, crescendal angina, acute coronary insufficiency, or intermediate coronary syndrome.

There were several classifications of unstable angina. In the widely used Braunwald classification, unstable angina pectoris was divided into three classes, corresponding to the degrees of severity:

• Class I - includes primary cases of severe or accelerated angina less than 2 months without residual pain.
• Class II - includes painful conditions at rest during the previous month, but not during the last 48 hours.
• Class III - Includes resting angina in the past 48 hours.

Currently, it is assumed that unstable angina is an intermediate condition between stable angina and myocardial infarction (MI). Unstable angina is often a common precursor to MI; in some studies, patients reported that they had chest discomfort consistent with the HC clinic in the week before a heart attack.

Prevalence of unstable angina

Each year, approximately one million Americans are hospitalized for developing unstable angina. A similar number of patients do not go to the hospital because they do not recognize themselves as sick or undergo treatment on an outpatient basis. Despite advances in medicine and improved survival after myocardial infarction (MI), the incidence of angina pectoris, as previously expected, is increasing, with various preventive measures being actively pursued.

According to the Global Registration and Evaluation of the Treatment of Unstable Angina (GUARANTEE), the average age of patients with NS is 62 years, 44% of these patients are determined to be over 65 years of age. Also, in patients with unstable angina pectoris, hypertension (60%), hypercholesterolemia (43%), diabetes mellitus (26%) are determined.

On average, women develop HC five years later than men, with about half of all women being diagnosed after age 65.

Pathogenesis

The formation of an intracoronary thrombus is believed to explain the pathogenesis in most patients with unstable angina. Unlike myocardial infarction with an increase in ST-segment level, in which the thrombus was usually occlusive, thrombus in unstable angina did not lead to complete occlusion of the coronary arteries, at least in 80% -90% of patients.

Thrombus formation in unstable angina

The main mechanisms for the development of unstable angina pectoris are intracoronary thrombosis and complex lesions (ulcerated or destroyed plaque), which are found in 50% -80% of cases.

The results of angioscopic studies indicate that an intracoronary thrombus or yellow plaque is found in the majority of patients with unstable angina pectoris, while similar cases with stable angina pectoris are quite rare.

A thrombus in unstable angina is characterized by a grayish-white color and presumably rich in platelets, while in MI it is more often red and erythrocytes predominate in it. Also, the formation of blood clots on a fissured or eroded plaque is the most common pathophysiological mechanism in unstable angina pectoris, especially when it comes to acute pain. In the absence of pain, additional studies should be carried out to identify a reliable cause of the development of NA.

Other pathogenic mechanisms of development of unstable angina

Inflammation plays an important role in the rupture of atherosclerotic plaques and contributes to the destabilization of the fibrous structure of the so-called vulnerable plaques by secreting matrix metalloproteinases. One of the difficulties in understanding the role of inflammation is the relationship between blood clots and inflammation. Tissue factor is more common in unstable versus stable plaques, with histological studies showing a strong association between macrophage infiltration and tissue factor localization. Local expression of tissue factor by macrophages can lead to activation of the coagulation cascade. In addition, platelet activation can lead to inflammatory reactions at the site of vascular lesions.

Lipoprotein (a) may be another link between inflammation and thrombosis. Recent research shows that lipoprotein (a), which is considered an atherosclerotic and thrombogenic factor, is localized in macrophage-rich areas as well as unstable plaques.

In general, the pathogenesis of coronary disease is directly related to the slow or rapid progression of atherosclerosis. On the other hand, ischemic mechanisms reflect an imbalance between myocardial blood supply and oxygen consumption. With unstable angina pectoris, a short-term decrease in blood supply or even a slight increase in the demand for the myocardium in the presence of a new significant lesion can accelerate the ischemic manifestations of the disease, namely NS, by changing this balance. A transient decrease in nutrition associated with the formation of an intracoronary thrombus with spontaneous lysis or embolization can also lead to the appearance of chest pain at rest. Activated platelets release several vasoactive substances, which in the presence of endothelial dysfunction (impaired vasodilation) can lead to distal vasoconstriction and a short-term decrease in blood flow. Although a blood clot is usually present in such cases, any process (thrombotic or otherwise) that significantly disturbs this balance can lead to unstable angina.

Causes and risk factors

The main cause of unstable angina is ischemic heart disease caused by the accumulation of atherosclerotic deposits on the walls of the coronary arteries. As a result of such pathological changes, the arteries narrow and become more rigid. This reduces blood flow to the heart muscle, then the myocardium lacks nutrients and oxygen, as a result of which chest pain is felt.

In case of unstable angina pectoris, the risk factors that are common to all cardiovascular diseases are taken into account:

• Diabetes
• Increased body weight
• Family history of heart disease
• High blood pressure
• High cholesterol and low-density lipoprotein levels
• Low high density lipoprotein levels
• Leading a sedentary lifestyle
• Having bad habits
• Chronic lack of sleep

If a patient has stable angina pectoris, then under the influence of the above factors of influence, it can turn into an unstable form.

Men over 45 and women over 55 are more likely to develop unstable angina.

Signs and symptoms

With unstable angina, symptoms may occur at rest; then become more pronounced, severe and prolonged than the usual picture of angina pectoris. There may also be a change in the usual picture of angina pectoris; or no improvement after resting or taking nitroglycerin.

The symptoms of unstable angina are similar to those of myocardial infarction (MI) and include the following:

• Chest pain
• Feeling of pressure in the region of the heart
• Pain or pressure in the back, neck, jaw, abdomen, shoulders, or arms
• Increased sweating
• Shortness of breath
• Nausea, vomiting
• Dizziness or sudden weakness
• Fatigue

The patient's medical history and diagnostic examination are important, and are usually more sensitive and specific for unstable angina than physiological examination, which may not provide significant information.

An objective examination of a patient with unstable angina pectoris can lead to the following results:

• Increased sweating
• Tachycardia or bradycardia
• Unstable myocardial dysfunction (eg, systolic blood pressure

Diagnostics

Various laboratory tests are carried out, among which the following are most often used to determine unstable angina:

• Standard 12-lead electrocardiography
• Sequential analysis of cardiac biomarkers (eg, creatine kinase, troponin, myoglobin, etc.)
• Complete blood count with determination of hemoglobin level
• Biochemical analysis of blood serum (including magnesium and potassium)
• Lipid panel

Coronary angiography helps visualize narrowed arteries or blockages. It is one of the most common tests used to diagnose unstable angina.

Other methods that may be helpful in evaluating patients with suspected HC include the following:

• Creatinine level
• Physical testing of the patient in stable condition
• Chest x-ray
• Echocardiography
• Computed tomography angiography
• Magnetic resonance angiography
• Single photon emission computed tomography
• Magnetic resonance imaging
• Myocardial perfusion imaging

Treatment

Treatment for unstable angina depends on the severity of the condition. Most often, in the treatment of NS, the tactics of exposure are selected in order to:

• Reducing myocardial oxygen demand
• Improving blood supply to the myocardium
• Risk assessments for progression of myocardial disease or treatment-related complications.

Patients with unstable angina should be treated in a hospital with continuous telemetry monitoring. Intravenous access is made and additional oxygen supply is provided, especially if signs of desaturation are noted.

In critical cases, when the clinical symptoms of NS are extremely pronounced, the method of primary treatment is used by an invasive (surgical) or conservative (medical) method.

In the treatment of unstable angina, the following drugs are used:

• Antiplatelet agents (aspirin, clopidogrel)
• Lipid-lowering statin drugs (simvastatin, atorvastatin, pitavastatin, and pravastatin)
• Cardiovascular antiplatelet agents (tirofiban, eptifibatide, and abciximab)
• Beta blockers (atenolol, metoprolol, esmolol, nadolol, and propranolol)
• Anticoagulants (heparin, low molecular weight heparin or enoxaparin, dalteparin, and tinzaparin)
• Thrombin inhibitors (bivalirudin, lepirudin, desirudin, and argatroban)
• Nitrates (nitroglycerin IV)
• Calcium channel blockers (diltiazem, verapamil, or nifedipine)
• Angiotensin-converting enzyme inhibitors (captopril, lisinopril, enalapril, and ramipril)

Video: How to cure angina pectoris

Surgical treatment for unstable angina may include the following:

• Inserting a coronary artery bypass graft - A portion of a blood vessel is taken from another part of the body and used to redirect blood around a blocked or narrowed part of an artery.
• Percutaneous coronary intervention - A narrowed portion of an artery is dilated with a tiny device called a stent.

Both of these operations are equally effective. The most optimal method of treatment is selected by the doctor, taking into account individual circumstances. Sometimes, even after surgery, you have to continue taking medication.

Prevention

Regardless of the severity of the condition, the patient may need to change his lifestyle, and with a focus on the long term, which is also the prevention of repeated attacks of unstable angina. The main recommendations from this area for improving heart health are:

• Practicing healthy eating
• Reducing stressful situations
• Weight loss, especially if there is excess weight
• Quitting smoking, if you have this habit

Lifestyle adjustments in most cases can reduce the risk of angina pectoris and heart attack. If necessary, you can discuss with your doctor the appropriate exercise options to avoid physical inactivity.

Forecast

The course of the disease largely depends on the severity of the disease. The stronger the pathological manifestations, the higher the risk of developing various complications that worsen the prognostic conclusion. If, in addition, the patient has concomitant diseases such as arterial hypertension or diabetes mellitus, then an unfavorable prognosis is also given.

Studies have shown that there are the following significant predictive factors for poor outcome in patients with unstable angina:

• History of poor left ventricular ejection fraction
• Hemodynamic instability
• Recurrent angina pectoris despite intensive anti-ischemic therapy
• New-onset or recurrent mitral regurgitation
• Persistent ventricular tachycardia

With timely initiation of treatment, the prognosis often improves, especially against the background of successfully performed revascularization or catheterization of the coronary arteries.

Video: ischemic heart disease. Unstable angina

Angina pectoris is one of the forms of ischemic heart disease (CHD), which is characterized by paroxysmal pain behind the sternum with an increase in the load on the cardiovascular system against the background of emotional and physical stress. The cause of the disease is a violation of the blood supply to the heart muscle. Unstable angina is a dangerous condition that threatens the development of myocardial infarction and related complications.

The reasons for the development of unstable angina

Disruption of blood supply to the heart muscle (myocardium) can be caused by various reasons. There are certain risk factors, which include:

• age - the chances of developing the disease increase in patients over 45;
• heredity;
• the presence of predisposing diseases such as diabetes, hypertension;
• overweight;
• lifestyle - smoking, alcohol abuse, stress, physical inactivity.

In men, the disease is diagnosed more often. In women before menopause, the risk of unstable angina pectoris is extremely low due to the production of sex hormones (estrogens) that preserve blood vessels. But after 50–55 years, the risk of developing the disease in women increases.

Atherosclerosis as a Cause of Ischemic Heart Disease

Cardiovascular diseases, more than 2/3 of which are coronary heart disease, stroke and peripheral arterial damage, are associated with atherosclerosis and remain the leading cause of death worldwide. Ischemic disease and angina pectoris most often occur due to a violation of the blood supply to the myocardium due to atherosclerosis of the coronary (supplying the heart) vessels. Plaques are deposited on their inner surface. At the same time, the vessels lose their elasticity, their walls ulcerate, which leads to the formation of blood clots. Atherosclerotic plaque can grow, deforming and narrowing the lumen of the artery, which causes chronic disruption of the blood supply to the organ. A local decrease in the diameter of the vessel by more than 50% can provoke an attack of unstable angina. The plaque can collapse due to inflammation, hemodynamic disturbances, excess body fat, and a lack of collagen. An unstable form of angina occurs when a plaque ruptures with the formation of a blood clot that interferes with the normal blood supply to the heart muscle.

Along with atherosclerosis, there are other causes of unstable angina pectoris:

• congenital defects;
• rupture of capillaries with subsequent hemorrhage into the plaque;
• inflammatory process in the vessels;
• increased ability of platelets to stick together;
• spasm of the heart vessels in infectious and rheumatoid diseases, a number of pathologies of the gastrointestinal tract;
• the release of serotonin or other biologically active agent into the blood, in which there is a sharp narrowing of the lumen of the coronary vessels;
• decrease in the antithrombotic properties of the endothelium (cells of the inner surface of blood vessels).

Disease types

The severity of the pain syndrome depends on the degree of arterial damage, the number and location of the damage. Depending on the characteristics of circulatory disorders in the coronary vessels, angina pectoris is:

1. First emerged. The first attacks can occur with severe physical exertion and vary in intensity. They last from a few minutes to half an hour. May grow or take place at rest. The prognosis is less favorable when, from the first attacks, the pain is growing, protracted and associated with changes in the ECG (electrocardiogram).
2. Progressive. It occurs already with the existing diagnosis of stable angina pectoris. It differs from its usual manifestations in a much longer and more intense attack. Usually, the usual dosages of nitroglycerin are not enough. In addition, seizures with various types of arrhythmias at rest are related to progressive angina.
3. Postinfarction (recurrent). Begins 24 hours or up to 8 weeks after myocardial infarction. According to statistics, repeated attacks are associated with the patient's activity or massive heart damage. In 20-40% can lead to death or repeated myocardial infarction.
4. Variant, or Prinzmetal's angina. The cause is narrowing of the coronary vessels in the form of spasm. It usually occurs at the same time and causes characteristic ECG changes that disappear after an attack.
5. With an outcome in small-focal myocardial infarction. It proceeds without visible rhythm disturbances and severe pain. It differs from other types of angina pectoris by pronounced changes in the ECG. The prognosis is often good.

Braunwald classification to determine the severity of the attack - table

	A - secondary unstable angina. Attacks are provoked by external causes (anemia, thyrotoxicosis, acute infection, etc.)	B - primary unstable angina. Associated with heart disease	C - postinfarction angina. Occurs within 2 weeks after myocardial infarction
I - new-onset, progressive angina pectoris, without rest angina	IA	IB	IC
II - angina at rest within a month, but not in the next 48 hours	IIA	IIB	IIC
III - rest angina in the next 48 hours	IIIA	IIIB	IIIC

This technique allows you to assess the risk of myocardial infarction by the clinic and the reasons for the pain attack.

Diagnostics

First of all, the doctor takes into account the patient's complaints, conducts a general examination of the patient, listens to heart sounds and collects anamnesis (history of the disease). To make a diagnosis, instrumental diagnostics are also used, which primarily includes an ECG. When an attack of angina pectoris occurs, you can notice a number of characteristic changes on the cardiogram.

In addition, a blood and urine test is prescribed. With unstable angina pectoris, biochemical parameters (levels of glucose, cholesterol, triglycerides, creatine kinase, etc.) can be changed.

Cardiac markers - troponins - have a special diagnostic role. They show the presence of damaged myocardial cells.

In the future, during inpatient treatment, an ultrasound of the heart - echocardiography, veloergometry, coronary angiography, Holter monitoring - is performed for in-depth diagnostics. Ultrasound can detect a violation of heart contractility and congenital defects.

Velgoergometry is a test in which the patient receives the load on the exercise bike to the maximum possible for him. At the same time, changes in the ECG are constantly recorded.

Coronary angiography is perhaps the most informative method. It consists in the introduction of a contrast agent into the vessels of the heart, which makes it possible to determine the ischemic area using an X-ray.

Holter monitoring is carried out more to diagnose rhythm disturbances at the time of an angina attack. The results are recorded within 24 hours.

Symptoms and differential diagnosis - table

Sign	Unstable angina	Stable angina	Intercostal neuralgia
The nature of the pain	The painful attack has a burning character, sometimes unbearable.	Has a typical burning character of chest pain.	Aching, aggravated by palpation along the nerve, paroxysmal, sometimes may manifest as burning or tingling.
Localization of pain	It is localized behind the sternum and is widespread.	Localized behind the sternum.	Localized in the intercostal spaces.
Irradiation (spreading) of pain	The pain radiates to the right or left arm, shoulders, under the shoulder blade, to the abdomen, neck, lower jaw.	The pain is usually localized only behind the sternum, rarely can be given to the left arm.	The pain radiates to the lower back, back, under the scapula, localized in the intercostal spaces.
Duration of pain attack	More than 30 minutes.	Up to 30 minutes after stopping any physical activity.	The appearance of pain with any movement, at rest is completely absent.
The beginning of the attack		During physical activity, at rest, in a dream, during stress.	When turning the torso, taking a deep breath, after making sharp turns or bending, when coughing or sneezing.
The reason for the attack	Atherosclerosis; systemic diseases; myocardial infarction; angina pectoris; smoking; taking alcohol; obesity; high pressure; stress; intense physical activity.	Intense physical activity, stress, atherosclerosis, systemic diseases.	Physical overstrain the day before, being in a draft.
Pain relief	Does not stop with the same nitroglycerin dosages	Stopped with three tablets of nitroglycerin.	The pain is not relieved by nitroglycerin, but is quickly relieved by systemic pain relievers (Analgin, Ketorolac, Diclofenac, Diclober, etc.).
Other symptoms	Nausea; vomiting; pallor of the skin; sweating; headache; epigastric pain; increase or decrease in pressure; excited state; increased body temperature.	May be accompanied by a rise in blood pressure.	Increase in blood pressure is possible.

Treatment of unstable angina

When treating unstable angina pectoris, several objectives must be achieved:

• restore vascular patency;
• relieve pain attack;
• prevent myocardial infarction;
• eliminate accompanying complications.

Drugs that the patient can take before going to the doctor

Treatment can be divided into first aid and medical aid. Independently, during an attack, the patient can take an aspirin tablet and up to 3 nitroglycerin tablets with a difference of 5 minutes. If the attack has not stopped, you need to see a doctor or call an ambulance.

It should be remembered that nitroglycerin must be taken in a horizontal or seated position under the control of blood pressure. If you are allergic to aspirin, you should limit your intake.

Treatments that reduce the incidence of complications

At the medical prehospital stage, drugs are injected intravenously to relieve an anxiety attack (nitroglycerin, Isomik, Isosorbide dinitrite, etc.), which help prevent thrombosis (Heparin, Streptokinase, Metalisa, Alteplase). With severe pain syndrome, it is possible to administer narcotic analgesics (Morphine, Fentanyl).

At the outpatient stage or in the hospital, different groups of drugs are added to the above treatment, regardless of the type of unstable angina pectoris:

• prolonged-release nitrates (used as nitroglycerin, but longer in action) - Molsidomin, Monocaps;
• beta-blockers (drugs to slow the heart rate) Bisoprolol, Metoprolol, Bicard, Propanolol;
• alpha-blockers (necessary to normalize blood pressure) - Lisinopril, Ramipril, Captopril;
• diuretics (used in the presence of edema and heart failure) - Torasemide, Veroshpiron, Indap, Furosemide, Spironolactone;
• statins (used to lower blood cholesterol) - Zokor, Atorvastatin, Rosuvastatin.

You cannot take these drugs without a doctor's prescription!

Applied medicines in the photo

Atorvastatin is prescribed by a doctor to lower blood cholesterol levels Bisoprolol - a drug that normalizes the heart rate Lisinopril is a drug designed to lower blood pressure The drug Molsidomin-LF affects vascular smooth muscles, reducing their tone Monocaps - means for normalizing the tone of the coronary vessels Veroshpiron is an effective drug for removing edema Ramipril is prescribed to lower blood pressure Furosemide - a remedy for the treatment of edema syndrome
Streptokinase is an effective drug for the treatment of blood clots
Aspirin is a blood thinner

Diet is important. The patient needs to limit the amount of fatty foods, you can not eat salty, spicy, fried, smoked. It is worth quitting smoking and alcohol. Physical activity, being in the fresh air, limiting stressful situations have a positive effect on the state of the body.

In addition, you can not skip taking medications prescribed by your doctor, you must comply with the prescribed dosages.

But do not forget that medications are only part of the prevention of unstable angina pectoris, it is equally important to maintain a healthy lifestyle.

Treatment prognosis

Unstable angina pectoris is an intermediate stage between the stable course of coronary artery disease and complications. In the absence of adequate care, the percentage of myocardial infarction is high. However, with timely hospitalization and initiated qualified treatment, the prognosis may be favorable.

How to protect your heart - video

Compliance with the doctor's recommendations, timely diagnosis and the use of prolonged nitrates can delay recurrent attacks, and in most cases prevent a heart attack. The role of the prevention of this disease is also increasing: the fight against risk factors for atherosclerosis, good nutrition, playing sports at any age.

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Treatment of unstable angina

The causes of unstable angina

According to modern concepts, unstable angina pectoris is referred to as acute coronary syndromes. is of particular clinical importance as a reversible condition. At this stage, further disturbances of the coronary circulation (myocardial infarction and sudden coronary death) can be prevented. About 10% of patients with coronary heart disease have signs of unstable angina.

The concept of unstable angina pectoris today includes the following clinical conditions:

• rest angina (pain\u003e 20 minutes) - diagnosed within one week after onset;
• de novo angina (angina pain attacks started 28 days ago) and exertional angina pectoris III-IV functional class (according to the classification of the Canadian Association of Cardiology) within 2 months after the onset;
• progressive angina pectoris - an increase in the frequency and duration of anginal attacks, their severity, an increase in the need to prescribe additional doses of nitroglycerin, or a decrease or complete absence of the effectiveness of nitrates;
• variant angina pectoris;
• postinfarction angina (more than 72 hours - up to 28 days from the development of myocardial infarction).

Classification of unstable angina pectoris by severity:

• I - recent start (< 2 месяцев) тяжелой или прогрессивной стенокардии напряжения; в состоянии покоя стенокардия существует;
• II - resting angina pectoris, subacute (\u003e 48 hours, there were no angina attacks);
• III - resting angina pectoris, acute (during the last 48 hours there are attacks of anginal pain).

Unstable angina pectoris develops as a result of such pathophysiological changes as rupture of atherosclerotic plaque, thrombosis, vasoconstriction, and inflammatory infiltration. Myocardial ischemia in unstable angina pectoris is a consequence of a decrease in blood supply, and not an increase in oxygen demand. We are talking about partial occlusion of the coronary artery in combination with spontaneous thrombolysis with well-developed distal collaterals or with alternating thrombosis-thrombolysis syndrome (ischemia-reperfusion).

Thrombosis is caused by active, or unstable, eccentrically placed plaques that have a lipid-rich core that occupies more than 50% of the total plaque volume, or so have a thin connective tissue capsule with few smooth muscle cells and a large number of macrophages (inflammatory cells). The rupture of the plaque lining promotes fluctuations in the tone of the coronary artery, which occurs in response to a sudden increase in the activity of the sympathetic part of the autonomic nervous system (a sharp increase in blood pressure, an increase in heart rate).

The rupture of an unstable atherosclerotic plaque usually occurs in the morning (especially during the first hour after a person wakes up); on Mondays, during the winter months, as well as on colder days of the year; with strong excitement (or immediately after); with strong physical exertion (or immediately after). The main cellular factors for early rupture of atherosclerotic plaque are macrophages and smooth muscle cells.

The most important sign of unstable angina is instability of the pain syndrome, which is manifested by the progression of exertional angina, the appearance of rest angina, the addition of new symptoms accompanying the pain (severe general weakness, cold sweat, shortness of breath, cough, chest bobbing, arrhythmia attacks at the peak).

With angina pectoris de novo, attacks of anginal pain are observed for 28 days against the background of complete health. This is usually exertional angina.

Subacute resting angina is diagnosed if the attacks of angina pain occurred more than 48 hours ago.

In acute angina pectoris at rest, attacks of anginal pain, on the contrary, are repeated within the last 48 hours.

However, progressive angina is of the greatest importance in the structure of unstable angina. A characteristic feature of progressive angina is compressive pain behind the breastbone, which either subsides or increases, does not disappear after the use of nitrates, accompanied by cold sweat, shortness of breath, arrhythmia, and fear of death. Episodes of attacks of anginal pain become more frequent, and interictal periods are shortened. Each subsequent attack is somewhat more severe than the previous one.

Pain may occur not necessarily in connection with psycho-emotional and physical stress, but also at rest. Sometimes only drugs eliminate it.

How is unstable angina treated?

And de novo angina requires hospitalization of the patient. Patients with pain syndrome, negative dynamics of the 5T segment, hemodynamic instability, pre- or syncope conditions, a high risk of death or the development of acute myocardial infarction require immediate hospitalization in the intensive care unit.

If there are no severe and prolonged attacks of rest angina in the last 2 weeks, the ECG is without pathological changes, the hemodynamics is stable, then the patients can be treated on an outpatient basis. Patients with unstable angina pectoris and moderate risk require medical dispensary observation.

The goal of treating patients with unstable angina pectoris is:

• early restoration of coronary patency,
• elimination or restabilization of pain syndrome,
• prevention of sudden coronary death and acute myocardial infarction,
• ensuring a satisfactory quality of life after rehabilitation.

Modern treatment of unstable angina pectoris includes medical and surgical approaches.

Medication treatment of unstable anginacarried out using:

• antithrombotic therapy (anticoagulant and antiplatelet);
• antianginal agents (D-blockers; nitrates; Ca2 + antagonists);
• metabolic therapy (korvaton, preductal);
• lipid-lowering drugs (statins, maxepa).

Antithrombotic therapy is used in all patients with acute coronary syndrome. Of the anticoagulants, unfractionated heparin is preferred - this is the most common antithrombotic drug for the treatment of patients with unstable angina. It should be used in the first 20 minutes from the moment of hospitalization of the patient. The introduction of heparin does not make it possible to maintain the anticoagulant state at a high level for a long time. For patients with unstable angina pectoris, this is very important, since the conditions for destabilizing atherosclerotic plaque can persist for weeks or months, and heparin is used only for 1-2 weeks.

The mechanism of action of aspirin is based on the ability to irreversibly inhibit COX-1, which is contained in platelets and promotes the conversion of arachidonic acid into prostaglandin endoleroxides, and then into thromboxane in the wall. Aspirin is rapidly absorbed in the stomach and upper intestines. The maximum level in blood plasma is reached after 15-20 minutes.

Clopidogrel is a potent selective blocker of ADP-induced platelet aggregation. The antithrombotic effect of clopidogrel consists in irreversible binding to ADP receptors on the platelet membrane, as a result of which platelet aggregation stimulated by ADP is suppressed. After oral administration, clopidogrel is rapidly absorbed and, after passing through the liver, is converted into an active metabolite, which interrupts in the blood plasma in a protein-bound state. The drug is excreted from the body through the kidneys, stomach and intestines.

Of the nitrates, patients with unstable angina pectoris with pain syndrome are prescribed nitroglycerin - 5 mg every 5 minutes. If, after taking 3 tablets of nitroglycerin, the pain does not subside, then nitrates should be administered intravenously around the clock in the form of a solution. Contraindications to the use of nitrates: intolerance to these drugs; arterial hypotension; ischemic or hemorrhagic stroke (in history); glaucoma; increased intracranial pressure.

Calcium antagonists are effective in patients with acute coronary syndromes in the presence of variant angina pectoris, destabilization of exertional angina of severe functional classes, and also when the patient has arterial hypertension, bradycardia, bronchial obstruction syndrome, decompensated diabetes mellitus, severe dyslipidemia. The therapeutic significance of calcium antagonists in unstable angina pectoris is to reduce energy costs and myocardial oxygen demand, improve oxygen transport to the myocardium due to vasodilatory action, reduce arteriole resistance, protect the myocardium from Ca2 + overload, and eliminate diastolic myocardial dysfunction.

Stabilization of the condition of patients with unstable angina pectoris means the absence of signs of myocardial ischemia and hemodynamic disorders during the last 24 hours. Under such conditions, one should switch to non-intensive treatment. At the same time, the administration of nitrates is canceled and their prolonged oral forms are prescribed. After 6-8 days, the use of therapeutic doses of unfractionated heparin and low molecular weight heparins is discontinued, but treatment with antiplatelet agents, ACE inhibitors and lipid-lowering agents is continued for at least 9 months.

For patients "stabilized" "for 2-3 days from the start of treatment, two alternative strategies can be used - early invasive and early conservative. The question is solved on the basis of coronary angiography. The purpose of non-invasive testing of a" stabilized "patient is to determine the prognosis for the next 6 -9 months and the choice of treatment tactics.

A patient with a low risk of complications, 48 \u200b\u200bhours after stabilization, is performed a physical or pharmacological electro-, echocardiographic stress test, 24-hour ECG monitoring.

After discharge, the "stabilized" patient is recommended to stop smoking, drinking alcohol, take measures to normalize the level of total cholesterol (no more than 2.9-3.0 mmol / l), conduct regular physical training 2 times a week, during which it is necessary to control the heart rate (up to 70% of the heart rate achieved during non-invasive testing), take aspirin (125 mg per day) or, better, clopidogrel (75 mg per day), β-blockers (in a dose sufficient to achieve a heart rate of 56-60 per 1 min).

The patient is monitored by a cardiologist for 4 weeks, and then he is transferred under the supervision of a local therapist or family doctor for further management.

What diseases can it be associated with

Against the background of angina pectoris, an attack may occur, dry cough, gurgling in the chest.

Untreated angina pectoris is fraught with development, progression, etc.

Treating unstable angina at home

Outpatient treatment is provided to patients who do not experience severe and prolonged angina attacks within 2 weeks after stabilization. An ECG without pathological changes and stable hemodynamics are the basis for outpatient observation of the patient.

Patients with unstable angina pectoris and moderate risk require medical supervision, including ECG monitoring, serial EchoCG recording, and determination of the levels of cardiac markers of myocardial damage and physical or psycho-emotional stress.

You should ask your doctor about recommendations regarding nutrition and lifestyle in general. The prescribed medications should be taken in strict accordance with the prescribed regimen.

What drugs to treat unstable angina?

• - the first dose is 5000 IU, it is administered as a bolus, and then they switch to infusion at an average rate of 1000 IU per hour under the control of partially activated thromboplastin time (APTT).
• - 1 mg / kg subcutaneously after 12 hours, within 6 ± 2 days, then - 0.4 ml once a day for 8-12 days.
• Lovenox - 1 mg / kg subcutaneously after 12 hours, within 6 ± 2 days, then - 0.4 ml once a day for 8-12 days.
• - 2.5 mg subcutaneously 1 time per day for 8-12 days.
• (Aterocard) - at a dose of 75-150 mg per day for 3-7 days.
• - intravenously in doses of 1-5 ml of solution, followed (after 1-2 hours) by ingestion of 40-80 mg per day after 6-8 hours during the first 8-12 days.
• - intravenously at a dose of 5 mg (administered within 1-2 minutes), the introduction is repeated at 5 mg every 3-5 minutes until a total dose of 15 mg is reached, then (after 1-2 hours) this drug is administered orally at 25-50 mg every 6 hours (up to 200 mg per day) for the first 8-12 days.
• - 20 mg once a day.
• - 2.5-5 mg once a day.
• - 2.5-5 mg or 10 mg once a day.
• - 80-240 mg per day.
• - 6-8 mg per day.

Treatment of unstable angina pectoris with alternative methods

The use of folk remedies in treatment of unstable angina not allowed. The attending physician can recommend infusions of medicinal herbs only at the recovery stage, when the condition is stabilized.

Treatment of unstable angina during pregnancy

Treatment of unstable angina during pregnancy, it is recommended to entrust it to a specialized specialist who, when determining the strategy, will take into account the woman's position, the results of her diagnosis and the cause of the development of angina pectoris. Fortunately, unstable angina is not common in pregnant women, as it is considered an older condition.

Which doctor should you contact if you have unstable angina?

The main signs of unstable angina on the ECG are elevation / depression of the 5T segment, inversion of the T wave, which can be kept for a day or longer (2-3 days, up to 10-14 days). On echocardiography, zones of hypo-, akinesia, dyskinesia of the walls of the heart are found, which disappear after a few days. When cardiomyocytes are damaged, the low-molecular-weight protein myoglobin enters the blood faster (after 2 hours) from serological cardiac markers. It can also be found in urine (myoglobinuria). However, this test is not specific because myoglobinemia and myoglobinuria are possible if skeletal muscle is damaged. In the first 6 hours from the onset of acute coronary syndrome, the level of total creatine phosphokinase and its MB fraction in the blood increases. This indicator normalizes after 24-36 hours, but it is also not sufficiently specific and sensitive.

The information is for educational purposes only. Do not self-medicate; for all questions regarding the definition of the disease and methods of treatment, contact your doctor. EUROLAB is not responsible for the consequences caused by the use of the information posted on the portal.