Myocardial infarction — a most dangerous condition that takes thousands of lives every day. Its complications are considered no less serious. One of them is postinfarction angina. It is she who increases the likelihood of a repeated cardiovascular catastrophe, which can become fatal.
Why does postinfarction angina occur?
Over the years of medical practice, I quite often met patients suffering from this disease, and now I want to share my observations with you. Angina pectoris after a heart attack is diagnosed in a quarter of all clinical cases. It represents the resumption of attacks of chest pain in the early (up to 2 weeks) or later (over 14 days). According to the classification adopted by the international cardiological communities, pathology refers to unstable forms of ischemic heart disease, which also includes the following types of "angina pectoris":
- vasospastic (Prinzmetal, variant);
- first appeared;
- progressive.
Based on my practical experience, I can conclude that most often this situation can be found after acute necrosis of the anterior wall of the heart muscle without lifting the ST segment on the electrocardiogram.
Postinfarction angina increases the chance of a fatal heart attack within the first year by up to 50%.
The occurrence of pathology is associated with extensive damage to the coronary arteries by atherosclerosis, dissection or rupture of plaque, stenosis of the vascular walls and the following functional disorders:
- coronary spasm - a sharp uncontrolled contraction of the muscular membrane of the heart vessels;
- incorrect work of hemocoagulation and fibrinolysis - specific processes responsible for blood coagulation;
- damage to the inner wall of the coronary arteries - endothelial dysfunction.
Common Causes
These include the following important intercurrent diseases and pathological conditions:
- hyperlipidemia - an increase in the amount of "unhealthy fats";
- diabetes mellitus - a disease associated with the pathology of carbohydrate metabolism;
- exogenous constitutional obesity - a significant increase in total body weight;
- the body's tendency to form blood clots (you can determine your body mass index here);
- arterial hypertension - an increase in pressure figures above 130/80 mm Hg. Art. (according to the American Heart Association);
- chronic stress - the release of specific hormones (cortisol, norepinephrine, adrenaline) negatively affects the vascular wall.
Specific factors
This group includes:
- residual narrowing of the coronary arteries after incomplete resorption of the thrombus by spontaneous or medication;
- significant postinfarction expansion of the left ventricular (LV) cavity;
- an increase in diastolic pressure;
- violation of systolic (contractile) function of the LV;
- a lesion that affects several important vessels of the heart at once.
Expert advice
- Take a lipid profile once a year. In case of poor performance, statins (Rosuvastatin, Atorvastatin) will help, as well as adherence to a diet that includes a large amount of green vegetables and excludes foods containing trans fats - pastries, margarine, ice cream, cakes, smoked meats, mayonnaise, crackers and others ... Read more about the diet after a heart attack here.
- Monitor your blood glucose levels. The most reliable indicator is glycosylated hemoglobin.
- Monitor your weight. Calculate your body mass index and adhere to the recommended guidelines.
- Take blood thinners as needed - "Clopidogrel", "Cardiomagnet" and others.
- Check your blood pressure regularly.
- Normalize your work and rest routine. Get rid of unloved work, spend more time with family, acquire a hobby. A good mood is the way to a healthy life.
Main manifestations
There are 2 variants of clinical manifestations of postinfarction angina pectoris. A typical picture is the onset of chest pains of a baking, burning character at rest or after little effort. The formation period is up to 4 weeks after an acute cardiovascular accident. They are able to give to the left half of the body - scapula, forearm, shoulder, angle of the lower jaw.
I want to note a special point - the pain syndrome in angina pectoris after a heart attack is poorly leveled with the help of nitrates and sydnonimines, therefore narcotic analgesics are often used.
Atypical symptomatology consists of the absence of severe anginal pain. Patients are worried only about the feeling of discomfort in the retrosternal region, but more often cardiac arrhythmias join - atrial fibrillation, extrasystole and others. The prognosis for this course of postinfarction angina is less favorable. Such a clinic is more common in males. In addition, the following are possible:
- increased heart rate;
- nausea, less often vomiting;
- instability of blood pressure;
- feeling anxious;
- dyspnea.
Diagnostics
When managing my patients, I always adhere to the following diagnostic algorithm. First, I interview the patient, then auscultate his heart and lungs. As a result, it is possible to identify a previous myocardial infarction, after which a characteristic pain syndrome appeared in the chest area. To clarify the diagnosis of "postinfarction angina", additional research methods are needed. We will talk about them further.
Laboratory diagnostics
It is used to exclude recurrence of acute myocardial infarction. To do this, the level of specific markers in the blood is determined, which speaks of heart damage - the myocardial fraction of creatine phosphokinase and troponins I and T. Their number in acute myocardial necrosis will be much higher. The troponin test becomes positive after 4 to 8 hours.
Instrumental methods
They are priority for the detection of postinfarction angina. Applicable:
- Electrocardiogram. It is not entirely specific, since it also records changes indicating a previous heart attack.
- Stress tests are the most informative, but they are used with caution and only when the patient is in a satisfactory condition. Treadmill, veloergometry, hyperventilation test may be prescribed.
- Holter ECG monitoring. It involves recording a cardiogram for several days.
- EchoCG is an ultrasound examination of the heart.
- Coronary angiography is a radiopaque method that detects vascular lesions. More often, the anterior descending and left coronary arteries are involved in the pathological process.
Clinical case
A 65-year-old woman, being treated in the cardiology department for an acute myocardial infarction, on the 7th day complained of a baking pain in the retrosternal region when trying to get out of bed, a feeling of nausea, an increased heart rate.
An ECG and troponin test were performed immediately. The latter turned out to be negative, but the cardiogram showed ST segment depression in leads I, AvL, V5-V6. These changes were interpreted as ischemia of the lateral parts of the heart muscle. A stress test (treadmill) confirmed the presumptive diagnosis of early postinfarction angina. The pain syndrome was successfully stopped by intravenous drip of "Nitroglycerin".Further treatment included statins, antiplatelet agents, and beta-blockers. The patient was discharged on day 21 with significant improvement.
The early form of the disease in this patient suggests that living myocardial cells are preserved in the lateral sections. Their death will contribute to a pronounced violation of the contractility of the heart muscle, and the risk of a second heart attack will significantly increase. In general, I can conclude that postinfarction angina has an unfavorable prognostic status. In 50% of cases, there is a need for surgical treatment.
Modern treatments
Treatment of postinfarction angina pectoris includes conservative therapy and surgery. The most effective drugs are beta-blockers (Nebivolol, Bisoprolol, Metoprolol succinate). If there are contraindications (AV block, bradycardia, sick sinus syndrome and some others), calcium antagonists ("Amlodipine") and prolonged nitrates ("Isosorbide dinitrate") are used. To improve the rheological properties of blood, I also prescribe antiplatelet agents (Aspirin) and anticoagulants (Heparin). However, with all due respect to the drug component, I believe that the best way to treat postinfarction angina is cardiac surgery. Stenting of the affected coronary vessels and coronary artery bypass grafting in most cases completely relieves patients of the manifestations of this disease. It is carried out 3 weeks after acute necrosis of the heart muscle.
