28.01.2021

Treatment of rest angina pectoris

The approach to the treatment of rest angina includes non-drug interventions for the correction of lifestyle, drug therapy, surgery for myocardial revascularization. The behavior model for rest angina requires refusing to smoke, use alcohol and energy drinks; adherence to a diet with cholesterol, animal fat, caffeine, salt; reduce overweight.

With an acute anginal attack, rest is necessary, immediate administration of nitroglycerin under the tongue. When a prolonged intractable attack requires a call to the ambulance. Planned treatment of rest angina pectoris is carried out by drugs of various groups; antiplatelet medications (acetylsalicylic acid), beta-adrenergic blockers (anaprilin, atenolol, propranolol), statins (atorvastatin, simvastatin), ACE inhibitors (enalapril), calcium ion antagonists (nadepine, verapamil, n-talipine, antagonists of calcium ions (nifedipine, verapamil), nitropylamine, antagonists of calcium ions (nifedipin, verapamil), antagonists of calcium ions (nifedipin, verapamil), antagonists of calcium ions (nifedipine, verapamil), antagonists of calcium ions (nifedipin, verapamil) or isosorbide dinitrate).

With rest angina, as a rule, there are indications for cardiac surgery. The operation of choice is balloon angioplasty and stenting of the coronary arteries. The results of coronary angioplasty are high – in patients with angina attacks cease, the contractile function of the myocardium improves. In some cases, the occurrence of restenosis – re-narrowing of the artery.

In severe or multiple lesions of the arteries, coronary artery bypass grafting is shown, with the creation of alternative pathways for coronary blood flow. In 20-25% of patients who have had CABG, angina resumes within 8-10 years, which requires re-operation of coronary artery bypass surgery.

Resting angina pectoris (decubital, postural angina pectoris) is one of the clinical forms of coronary heart disease, characterized by severe bouts of angina pectoris arising in a state of rest, out of association with physical stress. Resting angina pectoris in cardiology is considered as unstable angina pectoris and develops in patients with functional class IV disease. As separate variants of rest angina, Prinzmetal’s stenocardia caused by sudden unexpected spasm of the coronary arteries, and post-infarction angina, developing within 10-14 days after myocardial infarction, are distinguished.

Downstream I distinguish subacute angina of rest (if there are attacks in the last month) and acute angina of rest (if there are attacks in the last 48 hours). Resting angina pectoris is prognostically more dangerous than angina pectoris, and more often leads to a severe complication of IHD – myocardial infarction.

Causes of rest angina pectoris

The main cause of rest angina is coronary atherosclerosis. With rest angina, severe (usually three-vascular) lesion of the coronary arteries usually occurs. The morphological substrate of dynamic coronary obstruction is atherosclerotic plaque, often complicated by thrombosis and arterial spasm. Resting angina pectoris is associated with exertional angina pectoris as the lumen of the coronary vessels progresses, making it more severe.

In addition to atherosclerotic lesions, other diseases can contribute to myocardial ischemia, accompanied by an increase in oxygen demand of the heart muscle: arterial hypertension, hypertrophic cardiomyopathy, aortic stenosis, coronary, partial obstruction of the coronary arteries with thromboembolism or syphilitic ulcers, etc.

Since the attacks of rest angina in most cases develop during sleep, it is assumed that the pathogenesis of the disease is due to an increase in the tone of the vagus nerve.

Development of angina pectoris is often promoted by conditions aggravating myocardial ischemia (fever, anemia, hypoxia, infections, tachyarrhythmias, diabetes, thyrotoxicosis). In the series of non-modifiable (unremovable) risk factors for angina, age over 50-55 years of age, menopause in women, Caucasoid race, heredity are considered; modifiable (potentially disposable) factors include obesity, smoking, physical inactivity, metabolic syndrome, increased blood viscosity, etc.

Symptoms of rest angina

Attacks of anginal pain with rest angina develop against the background of complete physical peace when a person is in a horizontal position in bed, more often during sleep or early morning hours. The role of a kind of load, causing myocardial ischemia, with angina at rest performs an increase in venous flow to the heart in the prone position.

A sudden onset of rest angina pushes the patient to wake up from sudden choking or tightness in the chest. Attacks of rest angina occur in the phase of REM sleep, when there are dreams, so often the patient reports that in a dream he had to quickly run or lift weights. According to modern concepts, the phase of REM sleep is endogenous stress, accompanied by the stimulation of the autonomic nervous system and the release of catecholamines.

An attack of rest angina pectoris is accompanied by a state of heightened anxiety, anxiety, and the fear of death.

Pain syndrome is very intense; the pains are localized behind the sternum, have a constricting, oppressive character, spread to the jaw, scapula, left arm. The pain makes the patient freeze in one position, since the slightest movement causes unbearable suffering. Anginal attack is characterized by a longer duration (5-15 minutes) and severity, compared with exertional angina; It is often necessary to take 2-3 tablets of nitroglycerin to stop it.

Against the background of an anginal attack, pronounced vegetative reactions develop: tachycardia, rise in blood pressure, increased respiration, sweating, severe pallor or redness of the skin, nausea, dizziness. In most cases, nighttime episodes of rest angina pectoris are accompanied by exertional angina during physical activity during the daytime. An attack of rest angina pectoris, prolonged to 20-30 minutes, as well as an increase or increase in anginal pain requires immediate hospitalization and observation of the patient by a cardiologist.

Diagnosis of rest angina

A patient with rest angina requires inpatient examination with a full range of clinical, laboratory and instrumental diagnostics. On ECG with rest stenocardia, usually elevated or depressed ST segment, indicating the presence of critical stenosis of the coronary artery, arrhythmia and cardiac conduction; signs of postinfarction cardiosclerosis (abnormal Q wave and negative T wave).

Conducting stress tests (bicycle ergometry, treadmill test) for rest angina is not always informative – the results may be negative. Often, signs of ischemia can only be detected during daily ECG monitoring.

EchoCG is performed to all patients with rest angina, which allows to evaluate the contractility of the myocardium, to detect concomitant heart disease. The minimum biochemical blood test includes determining the level of total cholesterol, high and low density lipoproteins, AST and ALT, triglycerides, glucose; coagulogram analysis.

To assess the state of the coronary arteries and determine the treatment tactics, all patients with rest angina are shown to perform X-ray coronary angiography or its modern modifications (CT coronary angiography, multispiral CT coronarography). Cardiac PET (positron emission tomography) is performed to identify areas of ischemia and evaluate coronary perfusion. From resting angina pectoris, pains in pleurisy, intercostal neuralgia, esophageal diverticula, hernia of the esophageal opening of the diaphragm, ulcer and gastric cancer should be distinguished.

Prognosis and prevention of rest angina

The prognosis for rest angina is more serious than for angina pectoris: this is due to a more pronounced and, as a rule, multiple lesion of the coronary arteries. Such patients have a higher risk of myocardial infarction and sudden cardiac death.

Preventive work requires the complete elimination of modifiable risk factors and the treatment of associated diseases. All patients with rest angina should be constantly monitored by a cardiologist and, if necessary, be consulted by a cardiac surgeon.

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