Keywords: coronary heart disease treatment
With the rapid economic development of coronary heart disease in our country has become a common disease of endangering people’s lives, and coronary heart disease incidence increased year by year. Coronary heart disease accounted for only 6.78% of the hospitalized patients in the 1950s, 1980s, coronary heart disease accounted for 26.80% of the major diseases that cause human death. In some areas in the human cause of death, coronary heart disease accounted for first. According to the latest World Health Report, published in 2000, there is one in every three deaths worldwide die of the disease. So we have a good knowledge and understanding of coronary heart disease.
What is coronary artery disease?
Coronary heart called the coronary atherosclerotic heart disease, also known as ischemic heart disease. Caused severe atherosclerotic coronary artery stenosis or obstruction, or merger on this basis spasm, thrombosis aggravated lumen obstruction, caused by nutritional heart coronary insufficiency, myocardial ischemia, hypoxia or infarction occurred a heart attack. In general the degree of coronary stenosis ≥ 50%, can be said to coronary heart disease.
Second, the classification of coronary heart disease?
Coronary heart disease is divided into five types:
1, asymptomatic coronary artery disease;
, Angina, coronary artery disease;
3, myocardial infarction, coronary artery disease;
4, ischemic cardiomyopathy, coronary artery disease;
5, the sudden death of coronary heart disease;
Five kinds of coronary heart disease is a concrete manifestation of what?
Fourth, in the crowd which several types of common?
1, stable angina
Refers to the threshold of angina in the period of time maintaining a relatively constant. Coronary atheroma is relatively stable, the plaque without tearing ulcers, bleeding or thrombosis, arterial stenosis relatively fixed. When the cardiac workload 1:00 aggravate myocardial ischemia occurs temporarily, load lifting chest pain disappeared, a lesser degree of coronary blood flow obstacles.
(3) a meal;
(4) a cold;
(5) pain stimuli.
Typical performance: paroxysmal sternum upper or middle, precordial oppression or dull pain, chest discomfort, diffuse medial to the left shoulder and left upper arm, up to the ring finger or little finger, for 3-5 minutes, is generally not more than 15 minutes, may be associated with a fast heart rate, increased blood pressure, sweating, fear sympathetic activity performance, eliminate the incentive for rest or sublingual nitroglycerin drugs can relieve.
2, unstable angina
On the basis of such patients severe coronary lesions, usually unstable plaque rupture in coronary lesions at the merger due to thrombosis.
There are the following types:
(1) onset of angina pectoris;
(2) increase in the heavy-duty angina;
(3) post-infarction angina;
(4) variant angina;
(5) decubitus angina;
3, myocardial infarction
Refers to a coronary artery lesion suddenly completely blocked, Zhezhi coronary blood supply to the myocardium gradually necrosis and loss of function due to loss of blood supply to the presence of thrombus in coronary lesions, 90% AMI. Performance: heart area or sternum after severe unbearable chest pain was crushing resistance, there is a sense of impending doom, pain> 30 minutes or longer, accompanied by sweating, pale, fear, resting or taking nitroglycerin symptoms does not alleviate. Common complications of heart failure, arrhythmias, and cardiogenic shock, has a high mortality rate.
What is the treatment of unstable angina?
(A) General treatment:
(1) attack immediately rest;
(2) the removal of incentives;
(3) adjusting the diet and avoid eating greasy, ban alcohol and tobacco;
(4) adjust their daily lives and workload;
(5) reduce the mental burden;
(6) the appropriate physical activity, thus preventing pain for the degree;
(7) treatment induced deterioration of angina concomitant diseases;
(8) to reduce the risk factors of coronary atherosclerosis.
(B) drugs: A-aspirin or antithrombotic drugs; B-β-blockers; C-lowering agents; D-ACEI
1 nitrate preparations
(1) the mechanism: NO relaxation of vascular smooth muscle;
(2) Category: ① available categories: nitroglycerin; nitroglycerin oral spray; isosorbide dinitrate oral spray;
② efficiency class: isosorbide dinitrate; – single-NOx isosorbide;
(3) long-acting class: nitroglycerin ointment; nitroglycerin skin spray; nitroglycerin patch; 5 – isosorbide mononitrate sustained release preparations.
(3) side effects: palpitations, headache, elderly initial containing drug should be chosen small doses of nitroglycerin tablets (0.3mg / piece), in order to prevent the occurrence of hypotension.
(4) The mechanism of resistance group: ① SH group a lot of saltpeter consumption; ② sodium retention; ③ receptor insensitive.
(5) to avoid resistance methods: ① plus ACE inhibitors or diuretics; ② intermittent medication, no drugs should be between 8-12 hours.
(6) the rational use of nitrates
① For frequent angina patients choose the role of short duration drugs more effective than long-acting, isosorbide dinitrate and isosorbide excellent long-acting formulations of 5 – Single.
② In the time of administration of the drug:
▲ exertional angina, should be focused on during the day medication, such as isosorbide dinitrate can be 3 times / d / h, 5 – isosorbide mononitrate 2 times / d can be used, but should not be used 1/12h / or times / 8h.
▲ of the day, night, have early morning attack patients should isosorbide dinitrate 1/6 h usage, including time administration of 9Am 3pm, 9 pm3A m 1 / 4h, is not easy to adopt, easy-resistant.
▲ patients with nocturnal attacks frequent combination of short and long acting drug can be used, such as daytime isosorbide dinitrate three times / a long-acting formulations of evening clothes.
▲ patients only late at night, early morning attack, in addition to isosorbide dinitrate 1 / 6h regimens, long-acting formulations can be applied before bedtime, to choose the 12 hours before the release of more preparation is better.
▲ containing 5-10mg isosorbide dinitrate angina before getting up for the early morning wake up and easy to get up five minutes after the activity.
(3) the use of nitroglycerin or isosorbide dinitrate static point should note the following aspects:
The generally continuous intravenous drip should not exceed 48 h;
If more than 48 hours increased dose may be used, or the use of high and low concentrations used interchangeably;
Patients with symptoms during the day, during the day to give a higher dose at night to low doses or do not give.
(4) For the stable exertional angina patients, long-term service nitrates eliminate the heartache tia / d, 1 / 6h or 5 single isosorbide 2 / a.
Mechanism: blocking sympathomimetic amine stimulating effect on heart rate and cardiac contractility and slow down the heart rate, lower blood pressure, slowing of myocardial contractility and oxygen consumption, relieve angina pectoris.
Reduce movement, hemodynamic reflect the same amount of exercise the level of myocardial oxygen consumption, reduced non-ischemic myocardial small arteries narrow, thus allowing more blood to flow to ischemic areas through the extreme expansion of the collateral circulation. The dosage should be large.
Type: metoprolol (metoprolol) 12.5 mg-50 mg, 2 times / d;
Propranolol propranolol 10 mg / 10 mg ,3-4 each / 4h.
(1) of the drug can be used in combination with nitrates agent coordinating role, and thus a smaller dose.
(2) Disable the drug should be tapering, such as sudden stop can induce myocardial infarction;
(3) cardiac function, bronchial asthma,, and bradycardia discretion.
3, calcium channel blockers
Mechanism: inhibition of calcium into the cell, inhibit cardiac excitation – contraction coupling in the role of calcium and thus inhibit myocardial contractility, reduce myocardial oxygen consumption, expansion of coronary artery, the lifting of coronary artery spasm, improving subendocardial blood supply expansion of peripheral blood vessels, reducing arterial blood pressure, reduce cardiac stress, lower blood viscosity, platelet aggregation, improve myocardial microcirculation.
Types: (1) verapamil sustained release agent;
(2) nifedipine, nitrendipine, Man Mo horizon, non networks horizon, amlodipine besylate;
(3) diltiazem grass.
Note: (1) the treatment of variant angina the drug of first choice;
(2) the same service with nitrates;
(3) same clothes nifedipine with β-blockers, verapamil to diltiazem grass in combination with agents with β-receptor blocking;
(4) Disable the drug should be gradually tapered and then stop taking in order to avoid the occurrence of coronary spasm.
4, anti-platelet drugs
(1) Aspirin: inhibition of cyclooxygenase ‘suppression TXA2 formation, 50-300mg per day;
(2) ticlopidine, chlorine pioglitazone snow: inhibition of platelet surface ADP receptor without affecting aspirin block the cyclooxygenase channel;
(3) platelet glycated proteins: Ⅱ b / Ⅲ a receptor antagonists inhibit platelet-fibrin surface receptor is the final common channel;
Mechanism: dilation of blood vessels, inhibit renin – angiotensin aldosterone system improvement; ventricular remodeling and cardiac function, reduce angina abnormal.
Type and usage:
(1) a single coronary artery severe stenosis, myocardial ischemia objective basis, the greater the blood supply to the area of the lesion;
(2) multi-vessel coronary artery disease, but the disease is more limited;
(3) in the near future complete occlusion of blood vessels, the blood vessels that supply the area of viable myocardium distal visible collateral circulation;
(4) left ventricular function is severely impaired (EF <30% by);
(5) after coronary artery bypass angina;
(6) PTCA restenosis;
(D) the surgical treatment
The main purposes of the aorta – coronary artery bypass grafting. (CABG)
Surgical indications: coronary multivessel disease, especially in diabetic patients;
2, coronary main disease;
3, is not suitable for interventional treatment of patients;
4 myocardial infarction merge finished wall tumor, aneurysm resection, patients need to line;
Narrow segment of the distal lumen To smooth the vascular supply of viable myocardium.
(E) motion segment refining therapy
Appropriate exercise helps to promote the development of collateral circulation tolerated dose increase physical activity and improve symptoms.
Sixth, the treatment of unstable angina
Objective: to relieve angina and reduce the incidence of cardiac events, to improve the prognosis of the disease, improve quality of life.
(1) hospital bed rest;
(2) drug treatment: (1) strengthen the anti-platelet aggregation, anticoagulant cure;
Unfractionated heparin: play thrombolysis by activating antithrombin the indirect anti suppository, monitoring aPTT60-90S course of 2-5 days;
LMWH: is a complex of a small molecule by the composition, is a composite body, without monitoring APTT;
(2) more than medication with stable angina pectoris;
(3) myocardial maintenance drugs – Vasorel;
(3) interventional treatment CABG.
Treatment of acute myocardial infarction
General measures: bed; oxygen; pain; crown expansion.
2, reperfusion therapy:
① Mechanism and role;
② refers disorder;
④ side effects.
(2) emergency PTCA, ICS
Advantages: (1) thrombolytic contraindications allows patients with coronary vessels refilled;
(2) early clear coronary lesion group anatomy, in order to facilitate the development of more comprehensive program;
(3) to maximize the opening of blood vessels;
(4) improve cardiac shock patients; (70-80%) -40% cardiogenic shock patients line of business PTCA therapy is superior to other treatments;
(5) reducing the dirty portion urgent life-threatening complications occur;
(6) direct to PTCA dead thrombolytic Put less mechanical complications danger;
3, treatment of complications
4, to strengthen the anti-platelet therapy (antiplatelet therapy)
Conventional lipid-lowering B, ACEI, nitrates
Eight prevention and treatment of coronary heart disease
Including five levels:
1, anti-onset – primary prevention, prevention;
2, anti-event – keep atherosclerotic plaque stability;
Prevent the to thrombosis prevention of acute coronary syndrome and other serious incidents may be maimed or killed disease;
3, anti consequences – even if serious incidents such as ACS, how early identification, early intervention, to save the heart, to save lives.
4, anti-relapse – secondary prevention, to remedy the situation, it is not too late.
5, prevention and treatment of heart failure.
(A) anti-onset – primary prevention
Primary prevention is the most important source of cardiovascular disease: the control of multiple risk factors. Such as smoking, high blood pressure, abnormal blood lipids, diabetes, obesity, resting lifestyle. Modern mode – emphasizing the control while multiple risk factors.
1, applications related to multi-disciplinary and make concerted efforts, coordinated operations;
2, the control of risk factors for individualization.
Primary prevention is the most basic measures to change unhealthy lifestyles. The theme of the World Heart Foundation announced that the 2002 World Heart Day (September 29) “A heart for life" life needs a healthy heart, and to encourage public.
① increased physical activity, to promote aerobic exercise, such as walking, running, jumping rope, cycling, rollerblading, ball games, etc., the recommended rope skipping as promote aerobic.
② healthy eating and smoking cessation.
③ strengthen buck lipid lowering therapy.
The basis of acute coronary events caused varying degrees of thrombosis in unstable coronary artery plaque rupture, more than half of the event without aura, sudden onset, to reduce the the vicious incident rate, insist on lowering blood pressure, lowering blood pressure to strengthen antithrombotic therapy.
(3) Anti consequences
Even if the occurrence of acute coronary events, should strive to reduce or prevent disability or death consequences, and actively promote the use of anti-thrombotic vein to dissolve the clot, and lipids PTCA coronary stent interventional treatment.
(D) – secondary prevention of relapse prevention
This is a very high-risk groups for recurrence of serious cardiovascular events. There is sufficient evidence that the ABCDE line of defense significance.
A – aspirin ACEI
B – beta-receptor Yang the stagnation agent blood pressure control
C – lipid regulating smoking cessation
D – control of blood glucose control diet
E – exercise and education