Clinical tests and tasks. Tactics of pharmacotherapy of angina pectoris Variant angina is characterized by the occurrence of a painful attack

22. What ECG changes convincingly testify to coronary insufficiency during a bicycle test?

a. negative T wave reversal

b. prolongation of the PQ interval

c. ST segment depression more than 2 mm *

d. appearance of atrial extrasystole

e. transient blockade of the right leg of the bundle of His

23. What signs are not typical for variant angina pectoris?

a. transient rise of the ST segment on the ECG

b. coronary angiography reveals slightly altered or unaffected coronary arteries in 10% of cases

c. seizures occur more often at night

d. most effective calcium antagonists

e. exercise test is highly informative*

24. A 40-year-old patient complains of prolonged aching pain in the precordial region, not clearly associated with unrest, sensations of "punctures" in the left half of the chest. On examination, no pathology was detected, the ECG was without features. What research should be used to start the examination of the patient?

a. blood tests for sugar and cholesterol

b. from a blood test for lipoproteins

c. with echocardiography

d. with bicycle ergometry *

e. with phonocardiography

25. Factors that reduce the risk of developing coronary artery disease:

a. increase in the level of high density lipoproteins *

b. diabetes

c. arterial hypertension

d. hereditary burden

e. smoking

26. What pathogenetic mechanisms are not typical for angina pectoris:

a. stenosis of the coronary arteries

b. thrombosis of the coronary arteries *

c. spasm of the coronary arteries

d. excessive increase in myocardial oxygen demand

e. insufficiency of collateral circulation in the myocardium

27. The hemodynamic effects of nitroglycerin do not include:

a. increase in the number of heartbeats

b. decreased wedge pressure in the pulmonary artery

c. reduced left ventricular afterload

d. decrease in central venous pressure

e. increased myocardial contractility *

28. What is a contraindication for prescribing beta-blockers?

a. sinus tachycardia

b. ventricular tachycardia

c. paroxysmal supraventricular tachycardia

d. obstructive bronchitis *

e. arterial hypertension

29. What signs are not typical for left-sided intercostal neuralgia?

a. sharp pain on pressure in the intercostal spaces

b. increased pain on inhalation

c. relief of pain after taking analgesics

d. connection of pain with rotation of the body

e. positive effect after taking nitroglycerin *

30. What effects are not typical for the action of nitrates in angina pectoris?

a. increase in diastolic volume of the ventricles of the heart *

b. decrease in diastolic ventricular volume

c. improvement of blood circulation in the subendocardial layers of the myocardium

d. decrease in external work of the heart

e. increase in heart rate

31. What mechanism is not typical for the action of beta-blockers?

a. decrease in heart rate

b. bronchospasm

c. increase in cardiac output*

d. decrease in blood pressure

e. reduced exposure to endogenous catecholamines

32. What drugs have antithrombin action?

a. nitrates

b. beta blockers

c. calcium antagonists

d. anticoagulants *

e. antioxidants

33. The rise of the ST segment is a characteristic feature:

a. myocarditis

b. exudative pericarditis

c. constrictive pericarditis

d. Prinzmetal's angina*

e. aortalgia

34. A 57-year-old patient complains that during the year 1-2 times a month in the morning there are chest pains of a compressive nature, extending under the left shoulder blade, which disappear within half an hour after taking nitroglycerin. With Holter monitoring at the time of the attack, ST elevation in leads V2-V5 is 8 mm. Next day ST on the isoline. What pathology does the patient have?

a. stable angina of the 4th functional class

b. myocardial infarction

c. ischemic myocardial dystrophy

d. variant angina*

e. progressive angina

35. Which of the following variants of angina pectoris is an indication for hospitalization?

a. Prinzmetal's angina

b. new onset angina pectoris

c. rapidly progressive angina

d. frequent angina of exertion and rest

e. all of the above *

36. In the event of an acute attack of pain in the epigastric region and behind the sternum in middle-aged men, the examination should begin:

a. with gastric probing

b. with fluoroscopy of the gastrointestinal tract

d. with gastroduodenoscopy

e. with a urine test for uropepsin

37. Which statement about Prinzmetal's variant angina is correct?

a. ECG shows ST segment depression

b. an attack of variant angina is most often provoked by physical activity

c. variant angina occurs as a result of spasm of the coronary arteries *

d. to prevent seizures, it is advisable to use beta-blockers

e. variant angina refers to stable forms of coronary artery disease

38. A 46-year-old patient began to experience attacks of retrosternal pain at night, during which a transient rise in the ST segment was recorded on the ECG. Likely diagnosis?

a. Prinzmetal's angina*

b. recurrent myocardial infarction

c. development of postinfarction aneurysm

d. seizures are not related to the underlying disease

e. thromboembolism of the branches of the pulmonary artery

39. The most characteristic ECG sign of variant angina pectoris:

a. horizontal ST depression

b. ST depression with upward bulge and asymmetric T wave

c. lift ST *

d. deep Q waves

e. QS waves

40. The assumption of chronic coronary artery disease becomes most likely when:

a. describes a typical anginal attack *

b. there are symptoms of circulatory failure

c. detected rhythm disturbances

d. there are risk factors for coronary artery disease

e. revealed cardiomegaly

41. ECG signs of hyperkalemia:

a. high pointed T wave *

b. ST segment depression

c. T wave inversion

d. tachycardia

e. the presence of a Q wave

42. What is the criterion for a positive exercise test?

a. horizontal ST interval depression more than 1 mm *

b. the same less than 0.5 mm

c. downward-sloping ST interval depression less than 1 mm

d. Q wave enlargement in V5-V6

e. sinus tachycardia

43. Which of the following research methods is the most important for diagnosing coronary artery disease in doubtful cases?

b. load test *

c. phonocardiography

d. echocardiography

e. tetrapolar rheography

44. Which of the following drugs is the most effective antiplatelet agent?

a. sustaq-forte

b. aspirin *

c. phenylin

d. dichlothiazide

e. nifedipine

45. Patients who have had myocardial infarction are prescribed aspirin (acetylsalicylic acid) for a long time, because it:

a. lowers prothrombin index

b. prevents platelet aggregation *

c. lyses formed blood clots

d. inhibits the internal mechanism of blood clotting

e. the mechanism of the positive action of aspirin is unknown

46. ​​In what disease nitrates always worsen hemodynamics and can be dangerous?

a. hypertonic disease

b. dilated cardiomyopathy

c. hypertrophic obstructive cardiomyopathy*

d. aortic insufficiency

e. aortic sclerosis

47. Causes of variant angina (Prinzmetal type) are:

a. damage to the small vessels of the coronary artery

b. spasm of a large coronary artery

c. spasm of small vessels of the coronary artery

d. combination of atherosclerotic stenosis and vasospasm*

e. thrombosis of the coronary artery

48. Pain syndrome in hiatal hernia can be confirmed and differentiated from angina pectoris pain using the following methods and studies:

a. esophagoscopy

b. gastroscopy

c. fluoroscopy of the stomach with barium

d. angiography of the veins of the esophagus

e. radiopaque study of the esophagus when raising the foot end of the x-ray table *

49. The most severe course of angina is observed in patients with the following lesions:

a. stenosis of the main trunk of the left coronary artery *

b. proximal posterior coronary artery disease

c. distal circumflex artery lesion

d. proximal circumflex artery lesion

e. with a combination of proximal narrowing of the left and circumflex arteries

50. The limiting reaction of blood pressure during a bicycle ergometric test in patients with angina pectoris is:

a. increase in blood pressure up to 160 mm Hg. Art.

b. increase in blood pressure up to 170 mm Hg. Art.

c. increase in blood pressure up to 180 mm Hg. Art.

d. increase in blood pressure up to 200 mm Hg. Art.

e. increase in blood pressure up to 220 mm Hg. Art. *

51. In case of local stenosis of a large coronary artery, the optimal method of treating angina pectoris is:

a. conservative therapy with coronary drugs

b. transluminal angioplasty of coronary arteries *

c. destruction of atheromatous plaque with a cutting balloon

d. coronary artery bypass surgery

e. heart transplant

52. The optimal method of treating angina pectoris in case of damage to two or more coronary arteries by atherosclerosis throughout is:

a. coronary angioplasty

b. conservative therapy with nitrates + beta-blockers

c. conservative therapy with amiodarone + calcium antagonists

d. coronary artery bypass surgery *

e. implantation of an artificial pacemaker

53. An attack of angina pectoris is a situation that threatens the development of:

a. myocardial infarction *

b. paroxysmal tachyarrhythmia

c. ventricular fibrillation

d. asystole

e. rupture of the wall of the ventricle

54. Signs of stable angina pectoris of a high functional class can be:

a. change in ejection fraction

b. ECG signs of myocardial damage in the lateral wall

c. increased levels of LDH and CPK isoenzymes in plasma

d. lower threshold load on treadmill less than 50 W *

e. lowering the threshold load on the treadmill below 120 W

55. Which of the following drugs is the most effective in hypercholesterolemia?

a. a nicotinic acid

b. clofibrate

c. thyroxine

d. lovastatin*

e. probucol

Acute coronary syndrome

56. A 45-year-old patient receives heparin injections for unstable angina pectoris. As a result of an overdose of the drug, gastrointestinal bleeding developed. To neutralize heparin, you must apply:

a. fibrinogen

b. aminocaproic acid

c. protamine sulfate *

d. vikasol

e. all of the above is incorrect

57. A 52-year-old patient has attacks of retrosternal pain when walking fast and ascending to the third floor, which disappear within 5 minutes at rest or after taking nitroglycerin. on the ECG - a decrease in the voltage of the T waves in the chest leads. Over the past 2 weeks, seizures have become more frequent, they began to occur when walking at a normal pace. Holter monitoring at the time of the attack recorded sinus tachycardia, ventricular extrasystoles and ST depression, reaching 2 mm in leads V4-V6. The next day, on the ECG at rest in the same leads, persistent ST depression persists, reaching 1 mm. Probable diagnosis?

a. stable angina 2nd FC

b. myocardial infarction

c. stable angina 4th FC

d. Prinzmetal's angina

e. unstable angina *

58. The most characteristic ECG sign of progressive angina pectoris:

a. horizontal ST depression*

b. superior ST depression and asymmetric T wave

c. ST rise

d. deep Q waves

e. QS waves

59. Unstable angina pectoris is prognostically unfavorable in terms of:

a. development of myocardial infarction *

b. cerebral thromboembolism

c. development of fatal cardiac arrhythmias

d. development of pulmonary hypertension

e. development of venous insufficiency

myocardial infarction

60. A 60-year-old patient with arterial hypertension and angina pectoris developed shortness of breath, cough with frothy pink sputum. On admission: pronounced acrocyanosis, respiratory rate - 26 per minute, fine bubbling wet rales in the lower parts of the lungs. Heart sounds are muffled. Pulse - 120 per minute. BP - 90/70 mm Hg. Art. The liver is not palpable, there is no edema. These symptoms are typical for:

a. myocardial infarction

b. pulmonary embolism

c. dissecting aortic aneurysm

d. pulmonary edema *

61. A severe complication of myocardial infarction in the late period (after 2-3 weeks) is:

a. pericarditis epistenocardia

b. cardiogenic shock

c. Dressler syndrome*

d. arrhythmias

e. paresis of the stomach

62. Blood changes that are not typical for the acute stage of myocardial infarction:

a. increase in myoglobin levels

b. increased activity of aspartic transaminase

c. appearance of C-reactive protein

d. increase in alkaline phosphatase activity *

e. an increase in the CF-fraction of CPK

63. Which of the following drugs is the most effective antiplatelet agent?

a. sustaq-forte

b. aspirin *

c. phenylin

d. dichlothiazide

e. nifedipine

64. Which of the following ECG changes is not typical for myocardial infarction?

a. pathological Q wave

b. concordant ST segment elevation*

c. discordant ST segment elevation

d. low R wave voltage in the chest leads (R wave regression)

65. What serum enzymes are not elevated in myocardial infarction?

a. creatinine phosphokinase

b. lactate dehydrogenase

c. aminotransferases

d. alkaline phosphatase *

e. myoglobin

66. What treatment is not indicated in the first 6 hours of myocardial infarction?

a. thrombolytic therapy

b. anticoagulant therapy

c. digitalization *

d. calcium antagonist therapy

e. therapy with peripheral vasodilators

67. What complications of thrombolytic therapy are not observed in the acute period of myocardial infarction?

a. hypotension

b. anaphylactic shock

c. hemorrhagic shock

d. pulmonary edema *

e. hematuria

68. What signs are not typical for cardiogenic shock?

a. arterial hypotension

b. pulse pressure less than 30 mm Hg. Art.

c. bradycardia*

d. oliguria

69. Of the 5 patients whose ECG description is given below, 4 have a functional cardiac pathology, and 1 has an organic one. Specify the ECG of a patient with definitely organic cardiac pathology:

a. weakly negative T in the right chest leads

b. sinus arrhythmia

c. extrasystolic arrhythmia

d. QS complex in leads V3-V5 *

e. early repolarization syndrome

70. For posterior diaphragmatic localization of acute transmural myocardial infarction, the manifestation of changes in the following ECG leads is most typical:

a. 1st, 2nd standard leads, aVL

b. 2nd, 3rd standard leads, aVF *

c. 1st standard lead, V5-V6

e. AVL only

71. Which of the following laboratory parameters confirms the development of myocardial infarction in the first 4 hours from the onset of the disease?

d. alkaline phosphatase

e. glutamate transpeptidase

72. A 50-year-old man was admitted to the ICU with a typical clinical picture and ECG of acute anterior transmural myocardial infarction of the left ventricle, which was complicated by the development of complete atrioventricular block with a ventricular rate of 40 per minute. The most effective in this situation is the use of:

a. adrenomimetics

b. atropine

c. lasix

d. eufillina

e. placement of an endocardial electrode and temporary pacing *

73. The most accurate ECG diagnostic sign of transmural myocardial infarction is:

a. negative T wave

b. rhythm and conduction disturbances

c. the presence of the QS complex *

d. shift of the ST segment below the isoline

e. decreased R wave amplitude

74. What is Dressler's syndrome that develops in acute myocardial infarction?

a. ventricular septal rupture

b. atrial septal rupture

c. avulsion of the papillary muscle

d. autoallergic reaction *

e. none of the above

75. What symptom is typical for Dressler's syndrome?

a. increase in body temperature

b. pericarditis

c. pleurisy

d. an increase in the number of eosinophils

e. all of the above *

76. A patient with acute myocardial infarction (1st day) developed an attack of palpitations, accompanied by severe weakness, a drop in blood pressure. On the ECG: the P wave is not defined, the QRS is widened (0.12 sec) and deformed, the number of ventricular contractions is 150 per minute. Your diagnosis:

a. paroxysmal atrial fibrillation

b. ventricular paroxysmal tachycardia *

c. atrial flutter

d. sinus tachycardia

e. supraventricular paroxysmal tachycardia

77. A 48-year-old patient was taken to the ICU for acute transmural anterior septal myocardial infarction. Appeared shortness of breath, tachypnea, lowering blood pressure to 100/70 mm Hg. Art., tachycardia up to 120 per minute. Moist rales appeared in the lower parts of the lungs. In the 3rd-4th intercostal space along the left edge of the sternum, an intense systolic murmur with a gallop rhythm began to be heard. The oxygen saturation in the right ventricle is increased. Most likely diagnosis?

a. rupture of the outer wall of the ventricle

b. pulmonary embolism

c. ventricular septal rupture *

d. thromboendocarditis

e. epistenocardiac pericarditis

78. The most informative method for determining necrotic changes in the myocardium is:

a. determination of ESR and leukocytes

b. determination of LDH in the blood

c. determination of total CPK in the blood

d. determination of the level of transaminases in the blood

e. determination of the level of MB-fraction of CPK in the blood *

79. A patient developed a heart attack complicated by left ventricular failure. With the introduction of what drug should the treatment be started?

a. eufillin

b. lasix*

c. lidocaine

d. obzidan

e. heparin

80. Cardiogenic shock is characterized by all signs except:

a. decrease in blood pressure less than 80/50 mm Hg. Art.

b. tachycardia

c. acrocyanosis

d. decrease in total peripheral vascular resistance *

e. oligoanuria

81. A 45-year-old patient developed sharp pressing retrosternal pains radiating to the left shoulder blade after heavy physical exertion. Pain was relieved by ambulance with intravenous morphine. On admission: lethargic, pale, moist skin, cyanotic lips. Respiratory rate - 24 per minute. Hard breathing in the lungs, no wheezing. The heart sounds are muffled, the pulse is 115 per minute, weak filling. BP - 95/75 mm Hg. Art. The liver is not palpable. there are no edema. On the ECG: ST elevation in leads I, aVL, V5-V6, ST decrease in leads III, V1-V2. Likely diagnosis?

a. pulmonary embolism

b. posterior diaphragmatic myocardial infarction

c. anterior widespread myocardial infarction

d. anterior septal myocardial infarction

e. anterolateral myocardial infarction*

82. How should one classify worsening during the course of the disease, if at the 4th week of acute myocardial infarction a patient has intense compressive pain behind the sternum, a negative ECG trend has appeared and the activity of AST, ALT, CPK - MB has increased again?

b. recurrent myocardial infarction*

c. recurrent myocardial infarction

d. development of Dressler's syndrome

e. variant angina

83. A 52-year-old patient with acute anterior myocardial infarction developed an asthma attack. On examination: diffuse cyanosis, in the lungs a large number of wet rales of various sizes. Heart rate - 100 per minute. BP - 120/100 mm Hg. Art. What complication is most likely?

a. cardiogenic shock

b. pulmonary embolism

c. pulmonary edema *

d. ventricular septal rupture

e. none of the above

84. Hypovolemic form of shock is treated:

a. cardiac glycosides

b. eufillin

c. saluretics

d. plasma substitutes *

85. The most likely cause of increased intestinal atony in acute myocardial infarction may be the administration of the following drug:

a. morphine *

b. lidocaine

c. heparin

d. nitroglycerine

e. norepinephrine

86. What echocardiographic features are typical for myocardial infarction?

a. diffuse hyperkinesis

b. diffuse hypokinesis

c. local hypokinesis *

d. local hyperkinesis

87. A patient with a diagnosis of coronary artery disease - acute transmural anterior septal myocardial infarction, had frequent ventricular extrasystoles. Which of the following drugs should be administered to him?

a. strophanthin

b. lidocaine *

c. obzidan

d. finoptin

One of the rare manifestations of coronary heart disease is variant angina pectoris. This disease also has other names. It is called Prinzmetal's angina after the cardiologist who first described the disease. The third name most accurately represents the nature of the problem is vasospastic angina pectoris.

General information about variant angina

This type of angina occurs in 5% of cases of coronary heart disease. An attack of heart pain occurs against the background of rest, without overload, both physical and nervous. The immediate cause of the attack is a spasm of a coronary artery. At the same time, there is no increase in the oxygen demand of the heart.

Vasospastic angina can manifest itself in the earliest stages of atherosclerosis. Cholesterol plaques may not yet be formed, and a violation of the patency of large vessels is already present.

Attack triggers:

• Smoking,
• hypothermia,
• Binge eating.

How does the disease manifest itself?

The symptoms of variant angina are very similar to those of stable angina. In this case, there is no connection with loads. On average, an attack lasts from 5 to 15 minutes, sometimes up to 30 minutes. Patients are hard to tolerate attacks of Prinzmetal's angina, and they are quite difficult to stop.

Symptoms:

• Acute pain in the region of the heart of a pressing, burning character,
• increase in blood pressure,
• The person turns pale, covered with sweat,
• Headache,
• Nausea,
• Arrhythmia,
• Possible loss of consciousness.

Diagnostics

Diagnosis with this variant of angina pectoris can be difficult, since its manifestations are very similar to other types of the disease. The picture of the ECG at the time of the attack is often similar to the picture of myocardial infarction. However, in the case of vasospastic angina, ECG changes do not last long: only a few seconds or minutes, while with a heart attack they can last for about a month.

For diagnosis, differentiation with rest and exertion angina pectoris, infarction, and thrombotic occlusion is important. A complex of examinations is needed, including not only the usual ECG, but also bicycle ergometry, daily monitoring, ultrasound of the heart. The determining factor is the absence of cholesterol plaques in the clinical picture characteristic of coronary heart disease.

How to treat Prinzmetal's angina?

The treatment of variant angina is similar to the treatment of angina pectoris in general. It is important to conduct a complete diagnosis of the patient's body in order to identify concomitant diseases, especially those that can aggravate the course of angina pectoris. Treatment is aimed at preventing myocardial infarction and improving the quality of life.

Non-drug treatment

Lifestyle adjustment: nutrition, physical activity is the basis for the future life of a patient with angina pectoris. Compliance with the doctor's recommendations in this direction will help maintain the condition of the heart and blood vessels in an acceptable form. It is necessary to stop smoking. The level of regular physical activity is selected individually.

Medical treatment

• Long-term use of antiplatelet drugs,
• Beta-blockers, which counteract the effects of stress on the heart,
• Calcium antagonists will reduce the oxygen demand of the heart muscle,
• Nitrates (nitroglycerin, dinitrate) reduce the load on the heart, as they dilate blood vessels.

Invasive treatment

If it is impossible to effectively help the patient with conservative methods, they resort to surgery. This may be coronary angioplasty or coronary artery bypass grafting. However, with variant angina, the percentage of recurrence of the disease is quite high, so the decision is made only after a thorough examination and analysis of all the data.

Negative T wave reversal

Prolongation of the PQ interval

ST segment depression greater than 2 mm

The appearance of atrial extrasystole

Transient blockade of the right leg of the bundle of His

115. Which of the following variants of angina pectoris is an indication for hospitalization?

Prinzmetal's angina

New onset angina pectoris

Rapidly progressive angina

Frequent exertional and rest angina

All of the above

None of the above

116. If an acute attack of pain occurs in the epigastric region and behind the sternum in middle-aged men, the examination should begin:

With gastric sounding

X-ray of the gastrointestinal tract

With gastroduodenoscopy

Urine test for uropepsin

117. A 40-year-old patient complains of prolonged aching pain in the precordial region, not clearly associated with unrest, sensations of "punctures" in the left half of the chest. On examination, no pathology was detected, the ECG was without features. What research should be used to start the examination of the patient?

Blood tests for sugar and cholesterol

From a blood test to lipoproteins

With echocardiography

With bicycle ergometry

With phonocardiography

118. The following judgments regarding painless myocardial ischemia are correct, except:

It is most often detected in individuals with an established diagnosis of coronary artery disease.

The principles of treatment are the same as for typical angina pectoris.

The prognosis is the same as for the painful form of coronary artery disease

Diagnosis is based on ECG changes

Monitoring ECG is important

119. A 45-year-old patient receives heparin injections for unstable angina pectoris. As a result of an overdose of the drug, gastrointestinal bleeding developed. To neutralize heparin, you must apply:

fibrinogen

Aminocaproic acid

protamine sulfate

All of the above is incorrect

120. Which statement regarding Prinzmetal's variant angina is correct?

ECG showing ST segment depression

An attack of variant angina is most often provoked by physical activity.

Variant angina occurs as a result of spasm of the coronary arteries

To prevent seizures, it is advisable to use beta-blockers

Variant angina refers to stable forms of coronary artery disease

121. A 46-year-old patient, attacks of retrosternal pain began to occur at night, during which a transient elevation of the segment was recorded on the ECG. ST. Likely diagnosis?

Prinzmetal's angina

Recurrent myocardial infarction

Development of postinfarction aneurysm

Seizures are not related to the underlying disease

Thromboembolism of the branches of the pulmonary artery

122. All of the following factors increase the risk of developing coronary artery disease, except:

Increasing the level of high density lipoproteins

Diabetes

arterial hypertension

Hereditary burden

123. The most characteristic ECG sign of variant angina pectoris:

Horizontal ST depression

Upward ST depression and asymmetric T wave

ST lift

Deep Q waves

Expands coronary vessels

Reduces myocardial oxygen demand

Reduces myocardial contractility

Reduces plasma renin activity

Increases OPS

The assumption of chronic CAD becomes most likely when:

Described a typical angioedema

There are symptoms of circulatory failure

Rhythm disturbances detected

There are risk factors for coronary artery disease

Cardiomegaly detected

Which of the following does not correspond to angina pectoris?

Irradiation of pain in the lower jaw

Pain when climbing stairs (more than 1 floor)

Pain duration 40 min. and more

Identification of coronary artery stenosis

Pain is accompanied by a feeling of lack of air

The pathogenetic mechanisms of angina pectoris are as follows, except:

Stenosis of the coronary arteries

Thrombosis of the coronary arteries

Spasm of the coronary arteries

Excessive increase in myocardial oxygen demand

Insufficient collateral circulation in the myocardium

The most characteristic hemodynamic disorders in mitral stenosis:

Increase in EDV of the left ventricle

Increased pressure in the left atrium

Increase in cardiac output

Decreased pressure in the left ventricle

Which of the following research methods is the most important for the diagnosis of coronary artery disease in doubtful cases?

load test

Phonocardiography

echocardiography

Tetrapolar rheography

Which of the following symptoms can be observed in postinfarction cardiosclerosis?

Rhythm disturbance

Left ventricular failure

Right ventricular failure

Aneurysm of the left ventricle

All of the above

None of the above

Angina pectoris is one of the forms of coronary heart disease, the pathogenesis of which is based on a discrepancy between the need of the heart muscle for oxygen and its supply with the blood stream. One of the forms of this disease is Prinzmetal's angina, in which this discrepancy is realized through a transient spasm of the smooth muscles of the coronary vessels.

Variant angina (VSC), also known as vasospastic, or Prinzmetal's angina, named after the scientist who first described it, stands out as a form of unstable angina.

The characteristic features that distinguish it from other forms of this disease are:

Causes, pathogenesis and risk factors

A series of experiments on dogs carried out by Prinzmetal as early as 1959, in which temporary blockage of the branches of the coronary arteries was performed, gave a general idea of ​​the causes of this disease. According to the experiments, local myocardial circulatory disturbance during an anginal attack occurs due to a sharp increase in the tone of large coronary arteries. This, in turn, leads to a critical narrowing of the lumen of the vessels up to their temporary closure.

The pathogenesis of such an intense vasospasm, leading to a pronounced narrowing of the coronary arteries, is not known for certain, but the hypothesis of endothelial dysfunction is the most relevant.

The role of the endothelium in the processes of regulating the work of blood vessels is difficult to overestimate, because its total mass in the human body is about 1600-1900 g, which is more than the mass of the liver. In addition, a large number of mediators are synthesized in the endothelium, which are directly involved in the processes of vasoconstriction and vasodilation.

One of the most important among them is nitric oxide (NO), whose action is aimed at relaxing blood vessels. When the endothelium is disrupted (its dysfunction), there is a decrease in the production of NO and other endothelium-dependent vasodilators, which, with concomitant increased vascular reactivity, leads to clinically significant vasospasm.

Risk factors for developing Prinzmetal's angina include:

Symptoms

Anginal attack in vasoplastic form is characterized by severity and longer duration - from 10 minutes to half an hour. It is also not uncommon for a series of 2-5 seizures in a row to occur at short time intervals.

The localization of pain sensations is similar to that in other forms of angina pectoris - in the region of the heart, subjectively felt behind the sternum, often radiating to the lower jaw, left arm, shoulder blade. The nature of the pain is usually described by patients as pressing, squeezing, burning or cutting, of high intensity.

Also, the attack is most often accompanied by the following symptoms:

• pallor of the skin;
• headache;
• profuse sweating;
• nausea, rarely vomiting;
• tachycardia;
• hypo- or hypertension;

The non-attack period may not be accompanied by any signs of a violation of the cardiovascular system, even against the background of physical activity.

Pathogenetic features and specificity of the clinical manifestations of this disease cause the development of the following complications:

• arrhythmias (paroxysmal tachycardia, bundle branch block, ventricular fibrillation, ventricular extrasystole, AV block);
• transmural myocardial infarction;
• chronic heart failure;
• heart aneurysm;
• sudden coronary death.

Diagnostic procedures

The standard for diagnosing variant angina is the following diagnostic procedures, described in the table.

Although these methods greatly simplify the diagnostic search, they sometimes turn out to be insufficiently informative. Considering the transient nature of ECG changes, the use of this method, which is significant from a diagnostic point of view, is possible only in the form of Holter (daily) monitoring. After all, as already mentioned, in the non-attack period, there will be no violations on the cardiogram.

However, even if an anginal episode can be registered on daily monitoring, a specific rise in the ST interval may not be observed. This is explained by the fact that regular vasospasm and subsequent tissue hypoxia provoke a compensatory process of formation of additional vessels (alleles) in order to partially compensate for impaired blood circulation.

Therapeutic measures and prevention

Due to the severity of the disease and the high risk of complications, the treatment of Prinzmetal's angina should be carried out in a hospital. Drug therapy includes the following groups of drugs:

• calcium channel blockers (,);
• prolonged forms of nitrates (Isosorbide dinitrate, Nikoraldin);
• antiplatelet agents (Aspirin).

If it is necessary to provide emergency care with developed coronary spasm, anesthesia is indicated. For this apply:

1. Fentanyl with Droperidol or Promedol.
2. Nitroglycerin sublingually up to 6-8 mg / h.
3. (Nifedipine) - 10-20 mg sublingually.

In the absence of effect or with the first attack, urgent hospitalization in the intensive care unit.

Individual prevention of spastic conditions in patients with the vasoplastic form of this disease includes:

• to give up smoking;
• avoidance of known triggers of an attack: strong emotional shocks, hypothermia, hyperventilation of the lungs, morning physical activity;
• exclusion of taking vasoconstrictor drugs;
• general recommendations for all conditions associated with coronary artery disease: weight control, cholesterol levels, exclusion of a hypodynamic lifestyle, etc.

Forecasts

Given the severity of the disease, the prognosis is quite serious. Studies show that the survival of patients is 95% during the first year, 90% - after 2 years from the moment of diagnosis and 87% - in patients with a three-year "experience". The greatest number of complications occurs during the first three months from the onset of the disease.

However, with adequate therapy and dynamic supervision by the doctor, as well as compliance with preventive and therapeutic recommendations by the patient, good results can be achieved with a maximum duration and quality of life.

Vasospastic type angina pectoris is caused by pathological vasoconstriction, which entails an acute pain attack, accompanied by insufficient oxygen supply to the myocardium. In connection with more aggressive manifestations compared to other varieties of angina pectoris, it requires close monitoring by physicians, timely treatment in a hospital.

The treatment of heart pathologies should be approached very responsibly, as they are dangerous to human life. For example, there is such a type of angina pectoris as Prinzmetal's angina, which can lead to both a heart attack and sudden death. Such a state can be prevented if only one prepares for the possible consequences.

Specifics of pathology

In most patients, a proximal narrowing is found in at least one major coronary artery. Typically, the spasm occurs no further than one centimeter from the site of exacerbation and is often accompanied by ventricular arrhythmia.

Symptoms

The hallmark symptom of variant angina is attacks of pain. They most often occur in the mornings and at night, they can appear even without a good reason. Such pain comes from the region of the heart, is distinguished by a cutting and pressing character, and is also capable of radiating to other parts of the body. The attack itself can be described by listing its characteristic features:

• tachycardia;
• sweating of profuse type;
• hypotension;
• fainting;
• headache;
• skin pallor.

In some cases, the symptoms of variant angina can be as follows - failures in the rhythm of the heart muscle, ventricular fibrillation and atrioventricular block.

Most often, seizures last no more than fifteen minutes. Very rarely, the pain can last up to thirty minutes, it is very difficult to tolerate. Against the background of an attack, myocardial infarction can also develop, and therefore, with prolonged therapy, you should immediately call an ambulance.

What signs are not typical for variant angina? The fact that physical activity is poorly tolerated is extremely rare.

Diagnostics

Before starting all diagnostic procedures, the specialist will collect an anamnesis of life and family. After this, auscultation is performed, where noises are heard, and a physical examination. These manipulations are required for the differential diagnosis of variant angina pectoris, as well as for determining the initial diagnosis.

The patient is then given:

• blood and urine tests to detect comorbidities;
• a biochemical blood test to assess the concentration of protein, cholesterol and other elements that help determine the cause of the disease;
• ECG, which determines the main indicator of variant angina - the rise of the ST-segment;
• Holter ECG monitoring, which detects transient ischemia;
• provocative test accompanied by hyperventilation for angiospasm induction;
• cold and ischemic tests;
• coronary angiography, which detects stenosis in about half of the patients;
• bicycle ergometry, which determines the level of patient tolerance for physical activity.

In addition, a patient may be prescribed an MRI if a suitable modern device is available in the locality.

Treatment

Therapy of Prinzmetal's variant angina pectoris is optimally carried out in a hospital, as this allows you to control changes in the disease. Treatment is based on a combination of medical and therapeutic methods. Very rarely, the patient requires surgery.

Therapeutic method

The basis of the treatment method of variant angina is an absolute revision of all human life principles. The patient must give up his bad habits, stop drinking alcohol and smoking. In addition, it is very important to make adjustments to the diet:

• limit the intake of animal fats (in total calories - up to 30%);
• limit salt intake;
• reduce the use of spices and spices;
• drink multivitamins;
• pay special attention to vegetables and protein products.

The patient, along with these tips, needs to do exercise therapy, which includes cardio exercises.

Medical method

In the form of long-term drug treatment of variant angina, patients are prescribed:

As a long-term drug therapy, patients are prescribed: alpha-blockers; calcium antagonists; nitrates.

To stop angina attacks, the patient must take nitroglycerin under the tongue, as well as Nifedipine.

Surgical intervention

The operation is indicated only in the presence of a strong arterial narrowing and in cases where the development of angina pectoris occurs in the region of the heart. The following manipulations are used:

• angioplasty, in which the expansion of the vessel is carried out by means of a balloon and is fixed in this state with a metal awning;
• coronary artery bypass grafting, which means suturing one or another vessel of the patient to the coronary artery to start blood bypassing a narrower place.

Very rarely, the disease can affect the heart in such a way that it can no longer function on its own. In this case, he is shown the intervention of a surgeon.

Preventive measures

Preventive measures for variant angina come down to a number of general recommendations:

• a diet with a reduced content of salt and animal fat, increased - cereals and vegetables;
• exclusion of tobacco and alcohol;
• observance of the principles of the ratio of rest and work;
• eight hours of healthy sleep;
• avoiding stressful situations.

In addition, people who are at risk are advised to exercise regularly. Once every six months, everyone needs to go to a cardiologist to examine the patient for prophylaxis.

Complications

The most common complication of this form of angina pectoris is myocardial infarction, due to which a number of heart muscle cells die. In addition, if there is no competent treatment, the disease can lead to:

• severe tachycardia;
• arrhythmias;
• The most dangerous complication of the pathology is sudden death of the heart, which can be reversible with timely qualified assistance.

Forecast

It is difficult to predict the course of angina pectoris, since the condition is determined by the influence of various factors: the age of the patient, the strength of attacks, etc.

With mild heart damage, the probability of death is very low: about 0.5% per year.

If the damage to the heart is severe, death occurs in 25% of cases.