Anginal form of myocardial infarction. Myocardial infarction symptoms

25.05.2020

Algorithm for relief of anginal status

Algorithm for relief of anginal status (IHD: angina pectoris, myocardial infarction)

COMPLAINTS chest pain of a pressing, compressive character, less often baking, tearing;

with irradiation in the left arm, shoulder, under the shoulder blades, in the neck; with a feeling of lack of air, "fear of death."

OBJECTIVE pallor, cyanosis of the lips, shortness of breath; there may be sweating, tachycardia, lowering blood pressure. Urgent care:

1. Call a doctor!

2. Sit down the patient (unfasten the collar, loosen the belt of the trousers).

3. NITROGLYCERIN 1-2 tab. Under the tongue (or nitrosorbide, sidnopharm), in their absence - validol.

4. Control of blood pressure, pulse.

5. Intramuscularly: analgin 50% -2.0 + papaverine 2% -2.0 + diphenhydramine 1% -1.0 in 5 - 10 minutes!

6. E K G (required!)

7. Repeatedly: NITROGLYCERIN 1 - 2 tab. under the tongue.

in 5-10 minutes!

8. Intravenous jet; analgin 50% -4.0 + no-spa 2.0 + diphenhydramine 1% -2.0.

9. Oxygen inhalation.

10. Permanent venous access (dropper and intravenous catheter) in 5 - 10 minutes!

11. Control of blood pressure, pulse.

12. Calling the cardiologist on duty.

13. Intravenous jet: promedol 2% -1.0 + diphenhydramine 1% -1.0.

14. Intravenous drip: nitroglycerin 1% -2.0 + sodium solution chloride 0.9% -200.0.

after 15-20 minutes IF THE HELP IS NOT EFFECTIVE

15. Intravenous jet: a) fentanyl 0.005% -2.0 + droperidol 0.25% -2.0.

b) heparin 10.000 units.

c) can be repeated: promedol 2% -1.0 + cordiamine 2.0-4.0.

16. Continue intravenous drip infusion.

after 15 - 20 minutes IF THE HELP IS NOT EFFECTIVE!

17. Intravenous jet: sodium oxybutyrate 20% - 10.0.

Or anesthesia with nitrous oxide, hexenal.

In 15-20 minutes!

18. Intravenous stream repeatedly narcotic analgesics (fentanyl, promedol) + conventional analgesics + cordiamine 2.0-4.0 + lidocaine 10% -1.0 (2% -2.0).

19. Transfer to a specialized cardiology department (URGENT!) If the patient is transportable.

TICKET No. 46.

Rehberg-Tareev test. Methodology of carrying out. Interpretation of results.

Method for determining glomerular filtration (effective renal blood flow).

The clearance of endogenous creatinine refers to hemorenal tests, assessing the cleansing ability of the kidneys. The method is based on the calculation of glomerular filtration rate by the rate of plasma clearance from creatinine, which can be determined if you know the concentration of creatinine in the blood, urine and the volume of urine excreted for a certain time (usually a day).

Cleansing blood from metabolic products (depuration) is provided mainly by the kidneys (glomerular filtration, tubular secretion and reabsorption). Creatinine, on the other hand, refers to substances that normally enter the urine only by filtration and, after passing through the glomeruli, are not reabsorbed in the tubules. Therefore, a decrease in the excretion of creatinine in the urine and an increase in its concentration in the blood indicate a decrease in filtration in the kidneys. After 40 years, glomerular filtration decreases by 1% annually.

Glomerular filtration is determined by the formula: V (pl) = U (cr) x V (m) / C (cr) xT,

where V (pl) is the volume of plasma filtered through the renal filter per minute; V (m) - the volume of urine for a given time; C (cr) - concentration of creatinine in plasma (serum); U (cr) - urine creatinine concentration; T - urine collection time in minutes.

Since the minute volume of filtration in the kidneys depends on the height and weight of a person, in order to normalize the indicator in people significantly deviating in size from the average values, creatinine clearance is recalculated to the conventional value of the standard average body surface (1.7 m2). To do this, you need to know the height and weight of a person. This is especially important when carrying out the Rehberg test in children, since the corresponding age reference values are given in terms of a standard body surface.

Avoid physical activity, exclude strong tea, coffee, alcohol, observe the usual water regime, limit the intake of meat food. It should be borne in mind that taking corticotropin, cortisol, thyroxine, methylprednisolone, furosemide and others drugs may affect the amount of filtration, therefore, the conditions for the test should be discussed with your doctor in advance.

Simultaneously with the delivery of urine (at the end of the collection period), it is necessary to take a blood sample to determine the concentration of creatinine in it.

Indications:

Control of kidney function.

Endocrine diseases.

Assessment of the impact of high physical activity.

Units of measure for the Rehberg sample in the Independent Laboratory INVITRO: ml / min / 1.7 m2

Reference values

Age Men Women

< 1 года 65 - 100 65 - 100

1 - 30 years old 88 - 146 81 - 134

30 - 40 years old 82 - 140 75 - 128

40 - 50 years 75 - 133 69 - 122

50 - 60 years old 68 - 126 64 - 116

60 - 70 years 61 - 120 58 - 110

> 70 years 55 - 113 52 - 105

Note: Proteinuria and severe renal failure reduce the reliability of this indicator for assessing glomerular filtration rate. With a significantly increased concentration of serum creatinine, it begins to be secreted in the tubules, which causes an overestimation of glomerular filtration rates when calculated by the clearance of endogenous creatinine.

Level up:

the initial period of diabetes mellitus;

hypertonic disease;

nephrotic syndrome.

Decrease in level:

up to 30 ml / min / 1.7 m2 - a moderate decrease in renal function (does not matter on its own);

30-15 ml / min / 1.7 m2 - renal failure (compensated, subcompensated);

Fedorov Leonid Grigorievich

Ischemic disease heart, which proceeds with necrosis of areas of the myocardium, is called. There are several options for the development of heart disease, doctors distinguish between the typical and forms of the course of the attack. The form of the disease is characterized by certain signs:

intense pain in the chest area;
dyspnea;
cough;

Anginal form myocardial infarction is considered a typical variant of the development of the disease, it is found in medical practice most often.

Features and symptoms

The main feature is considered sharp pains... The resulting pain syndrome has the following symptoms:

constricting pain in the chest, as in an attack;
Spread pain not only to the region of the heart, but also to the whole chest, in some cases in the abdomen and lower jaw;
pain can be given to the left, less often to the right shoulder joint, sometimes a painful attack affects the patient's neck;
accompanying symptoms: cold clammy sweat, fainting, dizziness, in rare cases, vomiting and diarrhea.

The anginal form of a heart attack can be accompanied by so much severe pain that the offensive is possible cardiogenic shock... This condition is characterized by the following symptoms:

growing weakness;
weakness;
pallor of the skin;
a sharp decrease in blood pressure indicators;
cold perspiration.

Another feature indicating the onset of the anginal status of the disease is the inability to stop painful sensations with nitroglycerin.

Anginal myocardial infarction is the most common form of the disease, occurring in 90 percent of patients. Pain in the region of the heart is one-time, in some cases a whole series of wave-like pain attacks can occur, intensifying progressively.

It is noticed that in elderly patients there is often no pain (anginal pain), whereas in young people, severe (often unusual) pain is always manifested upon the onset of an attack. The duration of pain attacks varies from half an hour to 20 hours or more.

The anginal form got its name due to the localization of pain sensations (in some cases) in the throat or trachea, which, in terms of symptoms, is similar to angina.

Diagnostics

Basis of diagnosis pathological condition(especially in the first hours of an attack) - a detailed analysis of the nature of the pain, while the specialist must take into account the patient's history, indicating the presence of others. Further, constant monitoring of the dynamics of changes in indicators and control over the increase in the activity of enzymes in the patient's blood is carried out.

Use of neuroleptanalgesia. Currently, the main method of relieving intense coronary pain is curative, therapeutic neuroleptanalgesia (NLA).

In the proper sense of the word neuroleptanalgesia- This is a state of rest and absence of pain, achieved by the administration of antipsychotics and analgesics. In this case, the vegetative components of the pain reaction are softened, the shockogenic ones are eliminated, but vital reflexes involved in homeostatic regulation remain.

NLA can be caused by a combination of various antipsychotics and analgesics, but the most widely recognized variant of NLA II - the combination of fentanyl with droperidol - provides not only the necessary depth, but also flexibility, controllability of the effect.

Fentanyl is available in 0.005% solution, droperidol (dehydrobenzperidol) in 0.25% solution. For maximum positive effect and minimizing unwanted side effects doses of drugs providing NLA should be differentiated.

A dose of fentanyl 1 ml (0.05 mg) is recommended for patients weighing less than 50 kg, over 60 years of age or with concomitant lung diseases in the stage of pulmonary insufficiency. For the rest, the initial dose is 2 ml (0.1 mg).

The dose of droperidol depends on emotional state and baseline blood pressure: with systolic blood pressure up to 100 mm Hg. Art. - 1 ml (2.5 mg), up to 120 mm Hg. Art. - 2 ml (5 mg), up to 160 mm Hg. Art. - 3 ml (7.5 mg), above 160 mm Hg. Art. - 4 ml (10 mg).

Droperidol potentiates the analgesic effect of fentanyl without aggravating respiratory depression, therefore it is recommended to use NLA with predominant neurolepsy whenever possible, that is, there is more droperidol in volume than fentanyl, respectively 2-3 ml and 1 ml, 3-4 ml and 2 ml ...

The drugs are diluted in 10-20 ml of isotonic glucose or sodium chloride solution and injected slowly, at the rate of 1 ml of fentanyl for 2 minutes. If the doctor has neuroleptanalgesic drugs at his disposal, then pain relief should be started immediately with NLA.

It is a mistake to start with morphine and its analogs, and only after their insufficient effectiveness go to NLA as an extreme measure: the effects of morphine and fentanyl on respiration are cumulative and the risk of respiratory distress increases.

With NLA fentanyl and droperidol, the analgesic effect begins during the administration of drugs and sharply increases after 3-7 minutes, at the height of the action of fentanyl. Then the action of droperidol develops, and as a result of its potentiating effect, analgesia is enhanced for approximately 10 minutes. Thus, the main effect is observed in the first minutes, and it is possible to finally judge the degree of pain relief in 10 minutes.

"Emergency therapy", A.P. Golikov

Although recurrent and repeated myocardial infarction in general serve as evidence of the resumption of necrotic processes in the muscle tissues of the heart, there are differences between them. So a recurrent process is called a process that began less than two months after myocardial infarction. The second one develops after more than two months.

How to tell a relapse from a repeat ECG
Characteristic signs of relapse
Characteristic signs of a recurrent heart attack
How to avoid repetition

The classification of myocardial infarctions is quite extensive. It is distinguished by its shape, zone of localization, flow, rate of development, and so on. So recurrent processes can begin regardless of an already ongoing pathological process. But acute myocardial infarction is a rapidly developing pathology (both primary and secondary). Without proper treatment, follow-up and prevention, it is impossible to determine how beneficial the consequences will be. After all, IM is very dangerous disease bordering on the fatal risk to the patient's life.

The danger of myocardial infarction also lies in the fact that, in addition to serious consequences, none of the patients is immune from the second, third or more inflammations. Which only aggravates the condition of cardio-vascular system sick. Statistics show at least 25-29% of repetitions. Moreover, it is impossible to say who is more insured - a patient who follows a protective regime or leads a habitual lifestyle.

How to tell a relapse from a repeat ECG

Sometimes the localization zone is located as close as possible to the old scar, in the distance or in the area of another wall. And in these cases, the EC-gram will already indicate fresh heart attack changes.

In the event of a relapse, the pathological process in each new focus begins anew. It proceeds independently, regardless of the primary manifestation of myocardial infarction (that is, when the initial infarction has not yet completely healed). On the EC-gram it is noticeable in 70% of cases.

Characteristic signs of relapse

Recurrent myocardial infarction is insidious and can be confused with a protracted course. But an experienced doctor in the process of diagnosis will be able to expose the "deceiver." With a protracted course, the zone of localization of the primary manifestation increases, the most acute and acute periods all stretch and stretch. And in new hearths inflammatory process starts over. Therefore, the impression of "marking time" is created.

Primary infarction is considered here as large-focal or extensive, and is an acute violation of the coronary circulation. Its course is long, subdivided into four periods:

The most acute (0.5-2 hours) - a decrease in the blood supply to the area, the appearance of signs of tissue death;
Acute (2-10 days or more) - the formation of a necrotic area, muscle softening;
Subacute (up to 4 weeks) - the initial stage of scarring;
Postinfarction (3-5 months) - full-fledged scar formation, myocardial addiction to new working conditions.

Stenosing atherosclerosis of the coronary arteries - the most likely cause of recurrence

As a result of numerous observations, conclusions were drawn about the most likely causes of relapses. The main condition for this form of myocardial infarction is severe stenosing atherosclerosis of the coronary arteries with damage to collateral vessels. Not only does the coronary artery “turn off” due to thrombosis, but its ability to adequately expand is also impaired. Functional burden of the myocardium leads to the formation of new necrosis.

At the same time, one should not exclude the fact that a recurrent process can begin not only in the periphery, but also in the heart attack zone. This is due to the discrepancy between the need for blood supply and the state of coronary blood flow. As a result, the percentage of recurrent course ranges from 4% to 30%.

The following is observed:

decrease in the mass of the contractile myocardium;
increase in frequency chronic insufficiency blood supply;
exacerbation of cardiac arrhythmias;
increase in duration inpatient treatment(due to recurring infarction processes long time there is an acute period of the course);
the risk of death increases, including in inpatients (up to 35% of cases).

Variants of the clinical picture of relapse:

arrhythmic;
gastralgic;
asthmatic;
asymptomatic;
anginal.

This causes some difficulties in laboratory and hardware diagnostics. So, for example, if the attacks of pain at the initial heart attack were weak, and the patient was not hospitalized. Then later, with regular attacks and hospitalization, the primary heart attack is not an ECG will be invisible, while recurrent inflammation is seen better. The patient is diagnosed with myocardial infarction without indicating a relapse, and the initial symptoms are defined as a manifestation of angina pectoris. This can further affect the entire treatment process.

Another recurrence can be "hidden" under the pretext of complications of myocardial infarction, for example, arrhythmia. Recurrent processes of necrosis negatively affect the state of the patient's body. You may experience:

swelling of the respiratory system;
cardiogenic shock;
extensive necrotic lesion.

Characteristic signs of a recurrent heart attack

As mentioned, repeated myocardial infarction develops 2 or more months after the first case. At risk are middle-aged men who have had this disease. The recurrent course is severe, asthmatic and arrhythmic variants are often detected. Symptoms are already less pronounced, since in the previously affected areas of myocardial infarction pain sensitivity reduced.

The most common cause of any myocardial infarction is atherosclerosis, with plaque build up on the walls of the coronary arteries. A gradual decrease in the lumen, the sedimentation of thrombotic formations leads to complete occlusion. The supply of oxygen and nutrients contained in the blood stops in the tissue, which is why, in fact, the death of cells begins.

With repeated MI, atherosclerotic plaques do not disappear, sooner or later, occlusion cannot be avoided. If the process involves the same blood vessel, then necrosis is formed in the area of the scar of the first heart attack, if other vessels, then the repeated MI affects other walls of the heart.

Influencing factors:

the gender of the patient: men are more likely than women to develop heart disease;
age: for men there is a risk at any age, for women - after the onset of menopause; average indicators range from 45-50 years old and older, by the age of 70 the percentage of men and women levels off;
genetic predisposition;
overweight;
chronic endocrine diseases;
high blood cholesterol;
high blood pressure;
wrong way of life: food, regimen, bad habits;
psycho-emotional disorders, stress;
inadequate prevention of atherosclerotic disease or its absence;
non-compliance medical prescription sparing regimen after a heart attack: nutrition, physical exercise, smoking, alcohol.

Re-infarction is characterized by pressing or sharp pain in the region of the heart.

A repeated heart attack can develop in the same way as the first case, have the same course and symptoms. It is characterized by prolonged pain in the region of the heart, radiating to the left arm, forearm, interscapular space, neck, and lower jaw. Their nature is sharp or oppressive. The pains are not relieved by nitroglycerin, or are relieved partially, for a short time. Felt general weakness blanching is observed skin, hyperhidrosis.

The nature of the pain this time may differ somewhat from the previous manifestation of pathology. A heart attack usually has consequences, which leaves a negative imprint on each new outbreak.

Recurrent myocardial necrosis can occur without pain in the heart, but with signs of arrhythmic, abdominal or asthmatic variants:

shortness of breath;
breathing problems, pulmonary edema;
cyanosis;
loss of consciousness;
a sharp drop in blood pressure.

How to avoid repetition

In addition, you need to reconsider your lifestyle and try to exclude all possible influencing factors.

At risk are patients suffering from diabetes therefore, regular cardiac follow-up is imperative.

Prevention and rehabilitation after a heart attack are necessary to prevent postinfarction angina pectoris and repeated necrosis. TO medical recommendations relate:

Constant, continuous, lifelong intake of beta-blockers, antiplatelet agents and statins.
Lifestyle correction: regimen, nutrition, refusal bad habits, moderate physical activity.
Prevention or treatment of a psychoemotional state.
Bed rest (in the acute period and with recurrent myocardial infarction).
Exercise therapy by appointment.
Regular, non-grueling outdoor walks.
Sanatorium rest and treatment.
Temporary disability: long sick leave or transition to light forms of work. Note that a conditional period of 90-120 days is set for repeated MI. But in the case of vascular reconstructive surgery, sick leave is provided for a year.
It is not recommended for those who have suffered a heart attack to recover to work afterwards, if these are such professions: a pilot, a pilot, a driver of any type of transport, a dispatcher, a postman, a courier, a crane operator, a high-altitude installer, and so on. Daily employment and night shifts are also contraindicated.

Myocardial infarction has become significantly younger recently. This disease does not occur suddenly, it is preceded by many adverse factors, including vascular disease. An acute heart attack requires an urgent response, since in the absence of the first six hours of adequate treatment, the patient can simply die. Therefore, it is important for people at risk to regularly attend scheduled examinations with a cardiologist. And the rest too. After all, this same heart is the main engine of the human body!

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Anginous status

STATUS ANGINOSUS (lat.status anginosus) - pain syndrome in acute heart attack myocardium. Compressing, pressing, tearing, burning pain is localized more often behind the sternum or to the left of it, usually radiates to the left shoulder, arm, scapula, spreads to the right of the sternum, sometimes captures the epigastric region and "gives" to both shoulder blades; lasts for hours, and sometimes for days; is not stopped by repeated intake of nitroglycerin.

Use of neuroleptanalgesia. Currently, the main method of relieving intense coronary pain is curative, therapeutic neuroleptanalgesia (NLA).

In the proper sense of the word neuroleptanalgesia- This is a state of rest and absence of pain, achieved by the administration of antipsychotics and analgesics. At the same time, the vegetative components of the pain reaction are softened, the shockogenic ones are eliminated, but vital reflexes involved in homeostatic regulation remain.

Fentanyl is available in 0.005% solution, droperidol (dehydrobenzperidol) in 0.25% solution. To maximize the beneficial effect and minimize undesirable side effects, the doses of drugs that provide NLA should be differentiated.

A dose of fentanyl 1 ml (0.05 mg) is recommended for patients weighing less than 50 kg, over 60 years of age or with concomitant lung diseases in the stage of pulmonary insufficiency. For the rest, the initial dose is 2 ml (0.1 mg).

The dose of droperidol depends on the emotional state and baseline blood pressure: with systolic blood pressure up to 100 mm Hg. Art. - 1 ml (2.5 mg), up to 120 mm Hg. Art. - 2 ml (5 mg), up to 160 mm Hg. Art. - 3 ml (7.5 mg), above 160 mm Hg. Art. - 4 ml (10 mg).

Droperidol potentiates the analgesic effect of fentanyl without aggravating respiratory depression; therefore, it is recommended to use NLA with predominant neurolepsy whenever possible, i.e., in volumetric ratio, droperidol is more than fentanyl, respectively 2-3 ml and 1 ml, 3-4 ml and 2 ml ...

Clinical options (Anginal status).

All of the above indicates that with relapse, as with repeated myocardial infarction, the anginal status is absent mainly where the zones of relapse and previous necrosis coincide.

In general, the ratio of the clinical variant of myocardial infarction and recurrence is characterized by the following data.

Of 94 patients who underwent anginal myocardial infarction, relapse proceeded with pain attack in 64 people, in the form of an asthmatic variant - in 9 people, with status gastralgicus - in 7 people; arrhythmic form occurred in 13 people, "asymptomatic" - in 2 people.

Out of 7 patients who had an asthmatic variant of myocardial infarction, relapse proceeded with a painful attack in 3 people, in the form of an asthmatic variant - in 1 person; arrhythmic form occurred in 2 people and "asymptomatic" - in 1 person.

A patient who underwent a gastralgic form of myocardial infarction had a relapse with clinical picture status anginosus.

Of 3 patients with atypical myocardial infarction(2 patients with arrhythmic and 1 with cerebral variant) relapse occurred in 1 person as status anginosus, in 1 person as status asthmaticus and in 1 person as atrial fibrillation paroxysm.

Algorithm for relief of anginal status.

Algorithm for relief of anginal status (IHD: angina pectoris, myocardial infarction)

COMPLAINTS chest pain of a pressing, squeezing character, less often baking, tearing;
with irradiation in the left arm, shoulder, under the shoulder blades, in the neck; with a feeling of lack of air, "fear of death."
OBJECTIVELY pallor, cyanosis of the lips, shortness of breath; there may be sweating, tachycardia, lowering blood pressure. Urgent care:
1. Call a doctor!
2. Sit down the patient (unfasten the collar, loosen the belt of the trousers).
3. NITROGLYCERIN 1-2 tab. Under the tongue (or nitrosorbide, sidnopharm), in their absence - validol.
4. Control of blood pressure, pulse.
5. Intramuscularly: analgin 50% -2.0 + papaverine 2% -2.0 + diphenhydramine 1% -1.0 in 5 - 10 minutes!
6. E K G (required!)
7. Repeatedly: NITROGLYCERIN 1 - 2 tab. under the tongue.
in 5-10 minutes!
8. Intravenous jet; analgin 50% -4.0 + no-spa 2.0 + diphenhydramine 1% -2.0.
9. Oxygen inhalation.
10. Permanent venous access (dropper and intravenous catheter) in 5 - 10 minutes!
11. Control of blood pressure, pulse.
12. Calling the cardiologist on duty.
13. Intravenous jet: promedol 2% -1.0 + diphenhydramine 1% -1.0.
14. Intravenous drip: nitroglycerin 1% -2.0 + sodium chloride solution 0.9% -200.0.