Stable angina

Introduction to stable angina Stable angina is due to myocardial ischemia caused by labor, resulting in discomfort in the chest and nearby areas, may be associated with cardiac dysfunction, but no myocardial necrosis. It is characterized by a suffocating sensation of the anterior chest, which is mainly located behind the sternum and can be radiated to the anterior and left upper limbs. It can also radiate to the outer side of the right arm and the arms or the neck and mandible. It lasts for a few minutes and often disappears quickly after taking a break or sublingual nitroglycerin. basic knowledge Sickness ratio: 0.05% Susceptible people: no special people Mode of infection: non-infectious Complications: cardiogenic shock

Causes of stable angina pectoris

(1) Causes of the disease

The causes of angina include:

1 coronary atherosclerosis caused by stenosis of the lumen (usually above 75%).

2 coronary artery spasm, such as variant angina.

3 other coronary artery lesions: such as inflammation, embolism or congenital malformation.

4 non-coronary artery lesions: such as aortic stenosis or aortic regurgitation, syphilitic aortitis, severe anemia, hyperthyroidism, acne tachycardia.

5 hypotension, increased blood viscosity or slow blood flow.

6 hypertrophic cardiomyopathy, mitral valve prolapse, etc., the most important of which is coronary heart disease, that is, coronary atherosclerotic stenosis and / or coronary artery spasm.

(two) pathogenesis

Angina is a consequence of myocardial ischemia, caused by an imbalance between myocardial aerobic and oxygen supply, increasing heart rate, left ventricular wall tension and contractile force can increase oxygen demand; coronary blood flow and its oxygen content The amount of oxygen supplied to the myocardium.

1. Increased myocardial oxygen demand causes angina oxygen supply to be relatively constant, myocardial oxygen demand can cause angina pectoris, this condition is called myocardial oxygen demand increased angina, myocardial oxygen demand is usually released by sympathetic nerve endings What is caused by adrenaline is the physiological reaction of fatigue, emotional agitation or mental stress. When engaging in various activities, the increase or decrease of myocardial oxygen demand is of great significance. The hasty action and the forced use of second-handed exercise are particularly easy to induce. The effects of angina pectoris and emotional agitation on the ratio of oxygen supply to oxygen consumption are complex. Emotional stress increases sympathetic tone, reduces vagal activity, and increases blood pressure. Anger can cause contraction of the original narrow coronary arteries, but does not necessarily affect consumption. Oxygen, such as exercise after eating, and due to chills, fever, hyperthyroidism, increased metabolic needs due to various causes of tachycardia, etc., can also increase myocardial oxygen demand, resulting in stable stable stenosis patients with coronary heart disease The onset of angina pectoris (research confirmed that myocardial oxygen demand increased significantly in the onset of angina pectoris in this type of patient) Plus, especially the increase in heart rate is more obvious), unlike patients with unstable angina, patients with stable angina have a significant increase in heart rate before the ischemic attack, the possibility of ischemia and the increase in heart rate and duration Just proportional.

Myocardial ischemia usually has a fixed coronary stenosis, limited myocardial oxygen supply, fatigue, emotional or fever, and other factors that stimulate myocardial oxygen demand can induce myocardial ischemia, resulting in chest discomfort.

2. Temporary oxygen supply reduction caused by angina has been confirmed, the symptoms of unstable angina and chronic stable angina can be caused by temporary myocardial ischemia caused by coronary artery contraction, some people call it oxygen-deficient angina, Coronary bed has good innervation, multiple stimuli can change coronary tension, non-occlusive coronary thrombosis is another cause of oxygen supply reduction and angina pectoris, but often manifested as angina at rest. Angina pectoris, not chronic stable angina.

The degree of fixed stenosis in patients with typical stable angina is sufficient to cause insufficient coronary blood flow to meet the increased oxygen demand for exercise. On this basis, only a small coronary artery dynamic contraction is sufficient to cause coronary flow reserve. Further lack of function, the coronary blood flow drops below the critical level, causing myocardial ischemia.

3. Comparison of fixed threshold and variable threshold angina In patients with chronic angina, the range of angina thresholds can vary widely. Patients with angina pectoris who have a fixed threshold by increasing oxygen demand have essentially no vasoconstriction. Changes in composition, the level of physical activity that induces angina is relatively constant, and the patient can predict the amount of physical activity that induces angina. When the patient performs an exercise test, the blood pressure heart rate product that induces angina or ECG is stable or nearly constant.

Patients with varying angina thresholds, most of which have fixed coronary stenosis, coronary artery contraction can cause dynamic stenosis of blood vessels, which plays an important role in the mechanism of myocardial ischemia. The typical angina threshold can be changed, sometimes patients can Complete a considerable amount of physical activity without symptoms; sometimes mild physical activity causes clinical and/or electrocardiographic myocardial ischemia, and even angina can occur at rest, such as cold outside the environment, angina is prone to attack, This is because the former increases the peripheral vascular resistance at rest or during exercise, increases the arterial pressure, and decreases the threshold of angina by increasing the oxygen demand; on the other hand, it causes coronary artery contraction, which is the lowering of the angina threshold. One reason.

4. The term mixed angina is proposed by Maseri to describe many angina pectoris between fixed and variable thresholds, to understand the pathophysiology and clinical myocardial ischemia in patients with stable angina, and to select anti-myocardial defects. The blood drug and the time of administration are important. In the imbalance of aerobic and oxygen supply of the myocardium, the greater the proportion of the increase of oxygen demand, the greater the possibility that the beta blocker is effective, and the treatment of vasoconstriction The main cause of angina pectoris is that it is more effective with nitrate and calcium antagonists. Before the ischemic attack, there is an increase in myocardial oxygen demand, which means that there is an increase in oxygen demand angina, so you can choose blockers. As the main therapeutic drug.

The pathological basis of stable angina pectoris is the stability of its coronary atherosclerotic plaque, its plaque surface is smooth, no ulcers, bleeding, thrombosis and other acute factors exist.

Stable angina prevention

Because coronary heart disease is one of the most important diseases causing human death, and there is still no radical treatment in clinical practice, it is of great significance for the active prevention of coronary heart disease. The prevention of coronary heart disease includes primary prevention and secondary prevention. In one aspect, primary prevention refers to taking measures to control or reduce the risk factors of coronary heart disease in people who have not suffered from coronary heart disease, in order to prevent disease and reduce the incidence rate. Secondary prevention refers to taking drugs for patients who have suffered from coronary heart disease. Or non-pharmacological measures to prevent recurrence or prevent exacerbations.

1. Primary prevention measures include two situations:

(1) Health education: educate the whole population on health knowledge, improve citizens' self-care awareness, avoid or change bad habits, such as quitting smoking, paying attention to proper diet, exercising properly, maintaining psychological balance, etc., thereby reducing the incidence of coronary heart disease.

(2) Control high-risk factors: for high-risk groups of coronary heart disease, such as hypertension, diabetes, hyperlipidemia, obesity, smoking, and family history, etc., give positive treatment, of course, some of these risk factors can be Controlled, such as high blood pressure, high blood fat, diabetes, obesity, smoking, less active lifestyle, etc.; and some can not be changed, such as family history of coronary heart disease, age, gender, etc., treatment methods include the use of appropriate drugs to continuously control blood pressure Correct abnormal blood lipid metabolism, quit smoking and alcohol restriction, appropriate physical activity, control weight, control diabetes, etc.

2. Secondary prevention uses drugs that have been validated to prevent recurrence and exacerbation of coronary heart disease.

The drugs that have been confirmed to have preventive effects are:

(1) Antiplatelet drugs: Aspirin has been shown to reduce the incidence of myocardial infarction and reinfarction rate,

The use of aspirin after myocardial infarction can reduce the rate of reinfarction by approximately 25%; if aspirin is intolerant or allergic, clopidogrel can be used.

(2) -blockers: as long as there is no contraindications, patients with coronary heart disease should use beta blockers, especially after acute coronary events, there are data indicating that patients with acute myocardial infarction use beta receptors Blocking drugs can reduce the mortality rate and reinfarction rate by 20% to 25%. The drugs that can be used are metoprolol, propranolol, timolol and the like.

(3) statin lipid-lowering drugs: The results of the study show that long-term lipid-lowering therapy for patients with coronary heart disease not only reduces the overall mortality rate, but also improves the survival rate, and the number of patients requiring coronary intervention or CABC is reduced. In addition to lipid-lowering effects of statins, it improves endothelial function, anti-inflammatory effects, affects smooth muscle cell proliferation, and interferes with platelet aggregation, coagulation, fibrinolysis, and other functions, simvastatin, pravastatin, and chlorvastatin.

Statins and atorvastatin have this effect.

(4) ACEI: Mostly used in patients with severe impairment of left ventricular function or heart failure, many clinical trials have confirmed that ACEI reduces mortality after acute myocardial infarction; therefore, after acute myocardial infarction, ejection fraction <40% Or patients with wall motion index 1.2, and no contraindications, should use ACEI, commonly used captopril, enalapril, benazepril and fosinopril.

In addition, coronary angiography has coronary atherosclerotic mild stenosis and clinical symptoms have not yet developed ischemic symptoms, although it is not clear diagnosis of coronary heart disease, it should be regarded as a high-risk group of coronary heart disease, giving active prevention, also Long-term use of low-dose aspirin can be given, and risk factors such as dyslipidemia and hypertension can be eliminated.

Stable angina complications Complications cardiogenic shock

Stable angina increases the risk of both cardiac and non-fatal ischemic events.

Stable angina symptoms Common symptoms Visceral pain Chest pain Chest tightness Lung snoring Forced standing position Radioactive pain Asphyxia Coronary artery hernia Short weakness

Most patients showed that the onset of angina pectoris was stable for a period of time (more than 1 month), and its duration, severity, and threshold of angina pectoris were relatively stable, that is, the amount of physical activity causing angina pectoris was more predictable, and the symptoms of discomfort were rested. Or it can be relieved quickly after taking nitroglycerin.

1. Symptoms Typical angina has the following six characteristics:

(1) The nature of angina: For the same patient, the degree of pain in each episode may vary, but the nature of the pain is basically the same. The patient is often described as: "pressure", "squeezing", " The feeling of suffocation, the sense of "narrowing", the "swelling sensation" and the "burning sensation", etc., the pain of a knife-like or acupuncture is usually not angina, and sometimes the patient generally refers to it as a general narration of the nature of the pain. Chest discomfort, the patient generally uses his entire palm or fist to indicate the discomfort, and rarely uses a finger to indicate.

(2) Location and radiation of angina pectoris: Most angina pectoris is located behind the sternum, left anterior chest area, between the upper abdomen and the pharynx, and any part of the bilateral anterior anterior line. More than half of the patients have radioactive pain, the inside of the upper arm. It is a common site (this point is helpful for the identification of angina and cervical spondylosis, the pain of the latter just radiates to the outside of the upper arm), a small amount of pain starts in the upper arm and then radiates to the anterior chest. The same patient has more painful parts in the same period. Fixed, such as the expansion of the site, the increase of radiation sites suggest that the lesions are aggravated; the position of chest pain does not support angina pectoris, the range of angina is as small as a fist, a large piece, even throughout the chest; such as chest pain is dotted, linear distribution, does not support angina .

(3) Causes of angina pectoris: The most common predisposing factor for angina pectoris is physical exertion or emotional agitation, such as taking the road, the most likely to be induced when going up the stairs or uphill. This chest pain occurs at the time of fatigue rather than after, and often stops. After the activity, the symptoms disappeared quickly, walking against the wind, and the angina was often aggravated when walking cold or after a meal. The angina was prone to worsening under the physical load with emotional factors. It should be pointed out that the strength of angina in the same patient can induce it to vary from day to day. And it is different on the same day. The reason can be explained by careful questioning of medical history, such as eating, weather, emotional, etc. The threshold of angina is lower in the morning than at any time of the day, so patients often find it in the morning. The first time you perform an activity, it can cause angina, but it does not cause angina during the rest of the time or after the same activity. For example, regardless of the type of angina, the threshold changes greatly, and if it is significant at rest, it should be considered as The possibility of coronary artery spasm, therefore, careful medical history can not only show the cause of pain (such as myocardial ischemia) ), can also provide clues to the ischemic mechanism [such as coronary artery spasm and / or organic obstruction].

(4) duration of angina pectoris: angina pectoris is a paroxysmal attack, the whole process is generally 3 ~ 5min, severe episodes can reach 10 ~ 15min, more than 30min are rare, should be identified with myocardial infarction, intermittent chest pain or consistent with the heartbeat Jumping pain, chest pain that lasts for a few seconds is not like angina; if pain is a fuzzy and heavy feeling, and lasts for days or weeks, it is not like angina; angina is rarely affected by deep breathing.

(5) The method of relieving angina pectoris: If the activity is stopped, it can be relieved by standing for a few minutes in situ. When the angina pectoris occurs, the patient likes to take a standing position or a sitting position, and does not like the lying position. Sublingual nitroglycerin for 1 to 3 minutes can relieve angina pectoris; For example, if angina pectoris occurs 5 to 10 minutes after physical exertion, it is not necessarily the effect of nitroglycerin; severe angina pectoris, nitroglycerin has poor efficacy; oral nitroglycerin can prevent the onset of angina pectoris and increase the movement of patients with angina pectoris Tolerance; In addition, it should be noted that nitroglycerin is placed for more than half a year, and its therapeutic effect is gradually reduced.

(6) Accompanying symptoms: angina pectoris may be accompanied by chest tightness, shortness of breath, fatigue and weakness, and sometimes even the symptoms of angina are covered by these non-specific symptoms, which should be taken seriously.

Careful collection of the above six aspects of information is very important for the diagnosis of angina pectoris, it takes time, patience and skill, and inspiring questions often lead to misdiagnosis and should be avoided.

In some patients, the angina threshold can vary greatly because of the contraction of the coronary arteries on the basis of a fixed stenosis. Such patients can perform a large amount of physical activity at a certain time or within a day. Mild activity causes angina in another period of time. Patients often complain of circadian circadian variation. Angina usually occurs in the morning, low temperature, emotional agitation, mental stress can induce exertional angina, and sometimes even induce angina at rest.

2. Signs

(1) Systemic examination: Detailed physical examination can provide useful diagnostic clues and affirm the patient's risk factors. Checking during or after the onset of angina pectoris can improve the value of the diagnosis. The examination should not only target the cardiovascular system, but also special Pay attention to the existence of associated diseases that can affect the prognosis of coronary heart disease and the risk and expected effect of coronary revascularization surgery.

Looking at the eye can be found in the corneal arch (arcus corneae), the skin can be seen xanthoma (xanthoma), the size of the corneal arch seems to be positively correlated with age, cholesterol and low-density lipoprotein levels, the formation of yellow tumor and triglyceride concentration High and high-density lipoprotein are relatively lacking. Some investigations have found that the incidence of yellow tumor and corneal arch increases with age, and the highest incidence in patients with type II hyperlipidemia. In patients with type IV hyperlipidemia The incidence is the lowest, and changes in retinal arterioles are common in patients with coronary heart disease and diabetes or hypertension.

Blood pressure can rise slowly or rise sharply during the onset of angina (and heart rate increases). Blood pressure changes can occur before angina (promoting angina) or after (caused by angina). Other important findings of systemic physical examination are arterial pulsation and The relationship between venous system abnormalities, peripheral vascular disease and coronary heart disease is closely and fully affirmed. These relationships are not only seen in patients with symptomatic, clinically obvious peripheral vascular disease or carotid artery disease, but also in asymptomatic, but Patients with early carotid artery disease with reduced sputum-arm blood pressure index or ultrasound examination, palpation and auscultation if carotid artery and peripheral arterial disease are found, suggest that unexplained chest discomfort may be caused by coronary heart disease, check the patient's vein The system, especially for the evaluation of the lower extremity vein, is important for determining which transplantation method to use during coronary artery bypass surgery.

(2) Cardiac examination: murmurs of hypertrophic cardiomyopathy or aortic valve disease suggest that angina is not caused by coronary heart disease. Checking the heart during chest pain is often valuable. Physical examination reveals a transient left ventricle due to cardiac ischemia. Dysfunction, such as the appearance of a third heart sound or lung voice, angina can be heard during the first heart sound mitral valve component caused by ischemic left ventricular dysfunction; temporary second heart sound reverse split, due to Left and right ventricular contraction is uncoordinated, left ventricular contraction time is prolonged, resulting in delayed aortic valve closure. If there is no other obvious heart disease, a third heart sound or a loud fourth heart sound appears, suggesting that myocardial ischemia is the cause of chest pain. The 3rd and 4th heart sounds are more common in patients with angina at rest. When these patients do isometric exercise, even if angina is not induced, the frequency of the third heart sound and the fourth heart sound often increases, and the apical heart lift is common in Moderate or severe left ventricular dysfunction.

Stable angina check

Any laboratory test has little diagnostic value for stable angina, but can identify risk factors for coronary heart disease and secondary factors that cause angina; such as anemia, hyperthyroidism and hypoxemia.

1. Blood routine can be found whether combined with anemia, thrombocytosis and polycythemia, such as Hb and RBC decreased anemia, because anemia can reduce blood oxygen carrying capacity, increase cardiac load (Hb <90g / L and heart Increased load); if Hb <70g / L can occur STG changes on ECG, if there is polycythemia, thrombocytosis and agranulocytosis, because it can increase blood shear, induce angina pectoris.

2. Blood lipid and lipid disorders are closely related to the pathogenesis of coronary heart disease. The typical atherosclerotic lipid profiles are: TC (total cholesterol), LDL-C, VLDL-C, triglyceride and other increases in HDL-C.

3. Blood glucose to prove that glucose tolerance is reduced and diabetes is a risk factor for coronary heart disease. All patients with suspected coronary heart disease should be tested for fasting blood glucose.

4. Thyroid function combined with hyperthyroidism may have persistent tachycardia, T3, T4 increase; these hormones can cause heart rate to accelerate, increase metabolic rate, thereby increasing oxygen consumption; simultaneously activate platelets, causing coronary artery contraction, reducing oxygen supply, Induced angina.

5. X-ray examination of chest X-ray is normal or found heart enlargement, pulmonary congestion, the latter mainly seen myocardial fibrosis caused by chronic myocardial ischemia or myocardial infarction after heart enlargement, heart failure.

6. ECG is the most commonly used and most important method of examination, including resting ECG, load ECG and Holter detection.

(1) Resting electrocardiogram: This method is not sure whether there is coronary artery disease, because even in patients with very severe angina, the resting electrocardiogram is normal (about 50%), but the resting ECG can have coronary heart disease. Performance, such as the performance of old myocardial infarction or non-specific ST-T changes.

(2) Electrocardiogram at the onset of chest pain: Most patients with angina pectoris may have ST changes caused by paroxysmal myocardial ischemia, mainly characterized by ST segment depression of 0.1 mv (1 mm), recovery after seizure relief, and sometimes T wave inversion or Low level.

(3) Load electrocardiogram test: including sports plate and two-step exercise test, typical angina pectoris occurs during exercise; STG level or down-tilt type depression 0.1mv in ECG immediately after exercise or immediately, or the original ST segment decline After exercise, the body will drop by 0.1mv on the original basis, and will continue to return to normal after more than 2min; the blood pressure drop during exercise is a positive result, the negative standard: the exercise has reached the expected heart rate, and the ECG has no ST segment to fall or fall. Before <0.1mv.

(4) Dynamic electrocardiogram: symptomatic myocardial ischemia and painless myocardial ischemia can be found.

7. Echocardiography can detect abnormal movement of the ventricular wall in the ischemic area: exercise is weak, no movement and contradictory movement.

8. Coronary angiography coronary artery disease with >75% stenosis or left main stenosis >50%, can diagnose coronary heart disease.

9. Myocardial nuclide perfusion imaging examination of domestic 99mTc-pyrophosphate (99mTc-PyP), after injection can be quickly taken up by normal myocardium with coronary blood flow, its intake is directly proportional to coronary blood flow, because There is no blood flow in the scar after myocardial infarction, and it is a perfusion defect in myocardial imaging; if the coronary blood supply is insufficient, myocardial ischemia occurs, and in myocardial imaging, it is radioactively sparse.

Diagnosis and identification of stable angina

Diagnostic points

In the left lateral position, the abnormal pulsation of the apex can be touched. These pulsations are related to the location of the dyskinesia, supplementing the diastolic auscultation results. The transient apical systolic murmur is quite common, suggesting that due to transient myocardial ischemia The resulting papillary muscle dysfunction, such as persistent persistence, suggesting papillary muscle fibrosis, subendocardial myocardial infarction or local wall motion abnormalities, resulting in changes in the relative position of the papillary muscle, systolic murmur in the disease is heavier The majority of patients with coronary heart disease, especially those with myocardial infarction and left ventricular dysfunction, systolic murmur can be divided into early contraction, late or full systolic murmur, increased murmur during exercise or angina attacks, angina pectoris The mid-systolic click sound caused by mitral valve prolapse can also be heard during the period, followed by the late systolic murmur.

1. Diagnosis of angina pectoris depends mainly on symptoms, typical symptoms of symptoms can be established, in the diagnosis of coronary heart disease angina, must exclude angina caused by non-coronary diseases.

2. Classification of angina pectoris The classification criteria for the amount of physical activity induced by angina pectoris proposed by the Canadian Society of Cardioemia have been widely adopted. This is a modification of the functional classification of the New York Heart Association, but more specific than the latter classification. The grading standards are as follows:

Grade I: General daily activities do not cause angina, laborious, fast, and long-term physical activity causes seizures.

Level II: Daily physical activity is slightly limited, and it is more constrained after a meal, cold, and emotional excitement.

Level III: The daily physical activity is obviously limited. It can cause angina pectoris by walking 1 mile or upstairs at a general speed under normal conditions.

Grade IV: Slight activity can cause angina, even at rest. This grading depends on accurate patient observation.

Because the clinical tolerance of patients is very different, this grading standard also has certain limitations.

Differential diagnosis

Angina should also be differentiated from other diseases that cause chest discomfort.

Esophageal disease

(1) reflux esophagitis: due to relaxation of the lower esophageal sphincter, acidic gastric reflux, causing esophageal inflammation, paralysis, manifested as burning pain in the posterior sternum or mid-upper abdomen, sometimes can be radiated to the back and suspected angina, but the disease It usually occurs when lying down after a meal, and it can be relieved by taking an antacid.

(2) esophageal hiatus hernia: often accompanied by acid reflux, the symptoms are similar to esophagitis, often after bending or lying down after a meal, gastrointestinal angiography can be clearly diagnosed.

(3) diffuse esophageal fistula: can also be associated with reflux esophagitis, which can cause a variety of chest pain, taking nitroglycerin is effective, ergometrine can be induced, it is easy to suspect angina pectoris, is atypical angina A common cause of chest pain, according to the patient's history of acid reflux and anorexia, symptoms often occur when eating especially cold drinks or after meals, not related to fatigue, dysphagia at the time of onset can be distinguished from angina, esophagoscopy and esophageal manometry The law can be clearly diagnosed.

Clinically, angina pectoris and esophageal diseases often coexist, esophageal reflux can reduce the threshold of angina pectoris, esophageal fistula can be induced by ergometrine and relieved by nitroglycerin, so the identification of the two is often difficult, chest pain is "burning heart", and It is related to postural changes and eating. At the same time, dysphagia is a characteristic of esophageal pain. Esophageal pain is more common than angina to the back. Accurate diagnosis requires not only careful medical history and physical examination, but also laboratory examination.

2. Lung, mediastinal disease

(1) Pulmonary embolism: its pain suddenly occurs and occurs at rest. Patients with high risk factors (such as heart failure, venous disease, postoperative surgery, etc.) are often accompanied by hemoptysis and shortness of breath. The painful nature is typically It is described as a chest tightness accompanied by or subsequent pleural inflammatory chest pain, that is, the side of the chest is sharp and painful, breathing or coughing makes it worse, X-ray chest X-ray, pulmonary angiography, pulmonary radionuclide scan can be clearly diagnosed.

(2) spontaneous pneumothorax and mediastinal emphysema: both chest pains occur suddenly, the former chest pain is located on the side of the chest, the latter is located in the center of the chest, accompanied by acute dyspnea, X-ray chest can be clearly diagnosed.

3. biliary colic, this disease often suddenly occurs, the pain is severe and often fixed, lasting 2 ~ 4h, then can disappear by itself, no symptoms in the interictal period, generally it is the heaviest in the right upper abdomen, but can also be located Abdominal or precordial area, this discomfort often radiates to the scapula, can be radiated to the back along the costal margin, occasionally radiating to the shoulder, suggesting that the diaphragm is stimulated, often nausea, vomiting, but the relationship between pain and eating is uncertain This disease often has indigestion, abdominal flatulence, can not tolerate fat food and other medical history, but these symptoms are also common in the general population, the specificity is not strong, ultrasound imaging is accurate for the diagnosis of gallstones, and can understand the size of the gallbladder, gallbladder Wall thickness and whether there is bile duct dilatation, oral gallbladder angiography failed to show gallbladder filling, suggesting that the gallbladder is not functional.

4. Causes of nerves, muscles and bones

(1) Cervical radiculitis: It can manifest as persistent pain, sometimes causing sensory disturbances. Pain may be related to neck activity. Just as shoulder joint activity causes bursitis pain, the fingers are pressed along the back and have skin allergies. Area, suspicious and thoracic radiculitis, sometimes, cervical rib compression arm and shoulder plexus can produce angina-like pain, physical activity can also be found in the shoulder joint inflammation and / or shoulder ligament calcification, cervical spondylosis, similar to angina Musculoskeletal disorders, bursitis under the shoulders and costal cartilage.

(2) thoracic rib syndrome: also known as Tietze syndrome, the pain is limited to the cost of the costal cartilage and rib sternal joint swelling, tenderness, clinical manifestations of typical Tietze syndrome is not common, and costal cartilage inflammation caused by ribs and costal cartilage The tenderness (without swelling) is relatively common. At the time of examination, tenderness at the junction of the costal cartilage is a common clinical sign. Treatment of costal cartilage usually involves the elimination of doubts and anti-inflammatory drugs.

(3) Herpes zoster: chest pain may occur in the early stage of rash, and may even resemble myocardial infarction in severe cases. According to the persistence of pain, it is limited to the distribution area of skin sensory nerve fibers, the skin is extremely sensitive to touch and specific herpes. A diagnosis can be made that can make this disease.

(4) Unexplained chest wall pain and tenderness: palpation and chest activity (such as bending over, turning or swinging the arm while walking) can cause chest pain, contrary to angina pectoris, the pain can last for a few seconds or hours, nitroglycerin can not It is immediately relieved, generally does not require treatment, and even requires salicylate.

5. Functional or psychiatric chest pain It is a manifestation of anxiety in the circulatory debilitation. The pain can be located at the apex of the heart. It is a painful pain that lasts for several hours, often aggravated or transformed into a submammary sharp spur of 1 to 2 s. Pain, mostly occurs in emotional stress and fatigue, and has little to do with exercise, may be associated with tenderness in the precordial area, may be accompanied by palpitations, hyperventilation, numbness and tingling of the limbs, sigh, dizziness, difficulty breathing, whole body Signs of weakness and emotional instability or depression, other than analgesics, can not be alleviated, but can be alleviated by various forms of intervention, such as rest, labor, tranquilizers and placebo, and myocardial ischemic pain Conversely, functional pain is more likely to show different responses to different interventions, as functional pain often occurs after hyperventilation, which can cause increased muscle tone, a diffuse chest tightness, and some so-called functionalities. Chest pain may actually have the basis of organic disease, which is common in patients with mitral valve prolapse, and the nature of chest pain varies greatly between patients. Like the typical angina may Neurocirculatory debilitating disorder similar to chest pain.

6. Non-coronary atherosclerotic heart and vascular disease

(1) acute pericarditis: the age of onset is mild, often has a history of viral upper respiratory tract infection, the pain caused by inflammation is sudden onset, sharper than angina pectoris, position is leftward rather than in the middle of the chest, often radiating to the neck The pain is persistent and unrelated to fatigue. Breathing, swallowing and twisting the body can make it worse. When the patient sits up and leans forward, the pain is relieved. Auscultation has a pericardial friction sound, which can be clearly diagnosed by means of an electrocardiogram.

(2) Aortic disease: When there is sudden and severe pain in patients with high blood pressure, and the radiation to the back and waist, the possibility of aortic dissection is revealed; the continuous expansion of the thoracic aortic aneurysm can erode the limitation of the vertebral body. Severe drilling-like pain, especially at night; severe aortic stenosis due to insufficient coronary blood supply, angina can occur, systolic murmur in the aortic valve area and echocardiography can be identified.

(3) severe right ventricular hypertension: mitral stenosis, primary pulmonary hypertension and pulmonary heart disease can cause pain, this pain can also occur when pulmonary artery pressure, such as severe pulmonary stenosis with right ventricular hypertension, is currently considered The pain is due to limited cardiac output. In the systolic phase, coronary blood flow is reduced due to right ventricular hypertension, and oxygen consumption in the right ventricle is increased, resulting in poor myocardial perfusion. Therefore, chest discomfort can be caused by cardiac ischemia. The pain can be relieved by itself, and it lasts for a few minutes. Therefore, the reaction to nitroglycerin is difficult to evaluate. If the pain is caused by activity and can be prevented by nitroglycerin, the pain is likely to be caused by coronary heart disease. Many patients with pulmonary hypertension are exercising. ST segment shift occurs on the electrocardiogram after exercise.

(4) Chest angiography results of normal chest pain: angina pectoris or chest pain similar to angina pectoris with normal coronary angiography syndrome is often called X syndrome, need to distinguish from typical ischemic heart disease caused by coronary heart disease, the cause It is unclear that some of these patients have true myocardial ischemia, which is characterized by increased lactate production in the heart muscle during exercise or rapid pacing.

Patients with chest pain and normal coronary angiography are more common in premenopausal women. Most of the symptoms of chest pain are not typical. Chest pain can be induced by fatigue, but the threshold of pain is very variable. Sometimes the pain is very severe. This disease can affect the disease. The patient's work and quality of life, some patients may have panic, anxiety or mental abnormalities and other clinical manifestations, some patients have insulin resistance and hyperinsulinemia, clinical examinations and more abnormal findings, some patients may have non-special ECG on chest X-ray Heterosexual ST-T abnormalities, nearly 20% of patients have positive exercise test, motor nuclide myocardial imaging can be found in some patients with myocardial perfusion abnormalities, but it has no consistent correlation with the extent of the defect, the positive degree of exercise test and exercise tolerance.

For patients with clinical evidence of ischemia, nitrate and -blockers can be used, but the actual treatment effect is often unsatisfactory. Nitrate can not improve the exercise tolerance of patients with syndrome X, and even some patients Exercise tolerance, calcium antagonists can reduce the frequency and severity of chest pain in some patients, and can improve their exercise tolerance, in the course of treatment should try to find non-cardiac causes of chest pain, have gastric-esophageal reflux and esophageal function Disorders, treatment of these diseases is effective in relieving symptoms, and those who have no evidence of ischemia and/or those who are not responding to ischemic treatment, in addition to providing general supportive care, patiently explain the good prognosis of the disease to the patient, so that Peace of mind is also an important part of treatment.

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