Stable angina pectoris in the elderly

Introduction to stable angina in the elderly Stable angina pectoris is a common clinical angina pectoris, mainly in the absence of compensatory increase in coronary blood flow during physical activity to meet myocardial needs, resulting in myocardial ischemia, a clear cause of chest pain, the extent and duration of seizures The time is relatively fixed and the pain is relieved quickly after a break or nitroglycerin. basic knowledge The proportion of illness: 0.058% Susceptible people: the elderly Mode of infection: non-infectious Complications: acute myocardial infarction, arrhythmia, heart failure

The cause of stable angina in the elderly

(1) Causes of the disease

The vast majority (more than 90%) of angina pectoris is caused by coronary atherosclerotic lesions. When the stenosis caused by atherosclerotic lesions exceeds 50% to 75%, the oxygen consumption in the myocardium increases, but the coronary blood flow cannot. When increased, myocardial ischemia can lead to angina pectoris, other heart diseases such as aortic stenosis or reflux can also cause angina, especially in the elderly, due to degenerative changes of the aortic valve can make the valve thick, stiff or Calcification, a small number can develop into calcified aortic stenosis, severe coronary blood flow can cause angina pectoris, congenital bicuspid aortic valve to the elderly can also form severe calcific aortic stenosis, leading to angina Rheumatic aortic stenosis and reflux, can also cause angina in the elderly, in addition, hypertrophic cardiomyopathy, left ventricular outflow tract stenosis, aortic dissection, syphilitic aortitis and aortitis invading the coronary artery Can cause angina, some extracardiac factors such as severe anemia, hyperthyroidism, obstructive pulmonary disease, etc. can also affect the onset of angina.

(two) pathogenesis

1. Principle of myocardial ischemia

(1) Increased myocardial oxygen consumption: At rest, the myocardium takes 70% to 75% of oxygen from the coronary blood. Therefore, the increase in myocardial oxygen supply is mainly achieved by increasing the blood flow of the coronary arteries. Under normal circumstances, the coronary circulation has a good reserve force. When the myocardial oxygen consumption increases, the coronary artery expands correspondingly, which increases the coronary blood flow to meet the needs of the myocardium. For example, during strenuous exercise, the heart rate is increased and the coronary resistance is decreased. Coronary blood flow can be increased to 5-6 times normal.

When quiet, the coronary circulation is in a low-flow, high-resistance state; during exercise, sympathetic excitation and catecholamines increase blood flow through the vasodilating action of -adrenergic receptors; more importantly, adenosine when myocardial oxygen tension is reduced Metabolites such as lactic acid directly dilate small arteries to reduce vascular resistance and automatically regulate blood flow. Therefore, coronary circulation changes to high flow and low resistance during exercise. Coronary artery resistance mainly comes from small arteries, when coronary arteries are larger. When the degree of branch stenosis exceeds 50%, the stenosis part has a hindrance to blood flow, the maximum reserve of coronary circulation begins to decrease, the metabolic disorder caused by ischemia, activates the automatic regulation mechanism, causes the small artery to expand, and the large blood vessel is further narrowed and small. The arteries need to expand accordingly, and the blood flow can still remain normal at rest. When the heart is overloaded or the oxygen consumption of the myocardium increases beyond the blood volume provided by the expansion of the small arteries, temporary myocardial ischemia occurs. Hypoxia, which causes an episode of angina.

(2) reduction of myocardial oxygen supply: coronary artery blood supply decreased transient oxygen supply, leading to myocardial ischemia, is another important factor in the induction of angina pectoris, this primary blood supply reduction is mainly due to coronary artery occlusion When the coronary artery has a fixed obstructive lesion, the coronary artery stenosis or contraction, such that the degree of motility obstruction is slightly increased, the coronary blood flow can be lowered below the critical level, thereby causing myocardial ischemia-induced angina pectoris, some patients There is no obvious stenosis in the coronary arteries, severe motility obstruction (mainly coronary spasm), can also cause myocardial ischemia, leading to angina pectoris, non-occlusive coronary thrombosis, is also the cause of myocardial ischemia, often causing no Stable angina.

(3) Increased myocardial oxygen consumption and myocardial oxygen supply coexistence: excitement of sympathetic nerves during exercise or cold, increased heart rate, elevated blood pressure, increase myocardial oxygen consumption; and due to -adrenergic receptor nerves Excitement, vasoconstriction, resulting in reduced myocardial oxygen supply, angina caused by the combination of two factors, called mixed angina.

2. The main factor determining the myocardial oxygen consumption When the main stenosis of the coronary artery exceeds 50%, the myocardial oxygen supply can still be satisfied at rest, and the coronary artery is insufficient for blood supply during exercise, causing myocardial ischemia. It is to reduce myocardial oxygen consumption to improve exercise tolerance, the onset of angina pectoris, and the main factors determining myocardial oxygen consumption are as follows.

(1) Ventricular wall tension: related to intraventricular pressure during systole, heart size and wall thickness. According to Laplace formula, ventricular wall tension and ventricular pressure are proportional to ventricular radius, and inversely proportional to wall thickness, so when left When the ventricular systolic pressure or left ventricular volume increases, the ventricular wall tension increases, resulting in an increase in myocardial oxygen consumption.

(2) duration of myocardial systole: commonly used total ejection time per minute to illustrate, left ventricular perineal ejection time × heart rate = ejection time per minute, ejection, ventricular wall tension is the largest, the longer the ejection time, The more oxygen consumption, the time per pulse of blood injection, the increase in heart rate increases the ejection time per minute, so myocardial oxygen consumption is related to heart rate and ejection time.

(3) Myocardial contractility: The stronger the myocardial contractility, the greater the myocardial oxygen consumption. The heart rate, blood pressure and ventricular volume load are commonly used to estimate myocardial oxygen consumption. Heart rate × systolic blood pressure can also be used as a rough indicator to determine myocardial energy consumption. Oxygen content.

Myocardial oxygen demand increases with the increase in cardiac work, and the following factors can increase myocardial oxygen consumption:

1 elevated blood pressure, left ventricular hypertrophy, left ventricular outflow tract stenosis, exposure to cold environment and congestive heart failure, etc., mainly increase myocardial systolic tension and increase myocardial oxygen consumption.

2 The heart rate is significantly increased during exercise and emotional stress, which is the main factor for increasing myocardial oxygen consumption.

3 physical activity or the use of positive inotropic drugs, mainly by increasing myocardial contractility to increase oxygen consumption.

Stable angina prevention in the elderly

1. Appropriate physical exercise to improve the function of the myocardium and promote the formation of coronary collateral circulation.

2. Try to avoid factors that induce angina attacks, such as smoking, drinking, and emotional agitation.

3. Work and rest.

4. Reasonable nutrition, less use of high-fat foods.

5. Prevention and active treatment of diseases that cause angina, such as hypertension, obesity, diabetes, etc.

Stable angina complications in the elderly Complications acute myocardial infarction arrhythmia heart failure

Elderly patients with stable angina pectoris have a sudden occlusion of the coronary artery, which can lead to acute myocardial infarction, arrhythmia or heart failure.

Stable angina symptoms in the elderly Common symptoms Pale pale weakness, anxiety, dyspnea, arm pain, forced erectile systolic murmur, upper abdominal pain, chest pain, hypertension

Symptom

The main clinical manifestations of paroxysmal chest pain are mainly in the posterior sternum, but also in the left or pre-cardiac region. The pain is deep in the body and not in the body surface. The pain range is one piece, which may be accompanied by radiation pain. The pain site is relatively fixed. The nature of the pain is mostly sullen or oppressive. Even with the fear of sudden death, the patient often unconsciously stops the activity until the symptoms are relieved. The amount of physical activity that causes the onset of angina is basically fixed and can be predicted. Heart rate × systolic blood pressure as a rough indicator of myocardial oxygen consumption, the product value of angina is close to each time, angina is generally a sudden onset, lasting for a few minutes ~ 10 minutes, rapid relief after rest, most patients Good response to nitroglycerin, can be completely relieved 1 to 3 minutes after taking it. The elderly suffer from painful dullness, labor or emotional arousal. The location of angina pectoris and the nature of pain are not typical. Some patients may have no chest pain but a left arm or right. Arm pain, numbness of the fingers, or pain in the shoulders or shoulders, or pain in the upper abdomen, sometimes only as a breathing , weakness or fatigue without chest pain, and because the elderly often have emphysema and other organ diseases, angina pectoris can be induced by other diseases, or easy to cover up or confuse other diseases, resulting in difficult diagnosis, must be vigilant, In addition, the threshold of stable angina is not always fixed. If there is a slight change in coronary tension on the basis of stable coronary artery stenosis, the flow of coronary artery can be significantly reduced, and the exercise endurance will be significantly reduced. Clinical manifestations:

(1) First Effort Angina: For morning clothes, washing, toileting and other light physical activities can cause angina pectoris, but after this time, normal daily activities can be no discomfort, this is due to early morning coronary tension Due to the increase, coronary angiography confirmed that the morning coronary lumen was smaller than other times.

(2) Walking Trough Angina: angina pectoris on walking, the patient only needs to slow down, continue to walk angina can disappear, then resume the original walking speed, angina does not attack, this phenomenon and coronary artery tension when starting to walk Increased related.

(3) Stable angina pectoris: patients are more likely to attack in cold air. The effect of cold air on the pathogenesis of angina has two aspects: one is cold vasoconstriction, the surrounding resistance increases, the left ventricular pressure load is aggravated, and the myocardial oxygen consumption is increased. Increased angina pectoris, second, cold can also cause coronary artery contraction, reduce blood supply to the coronary artery and induce angina.

2. Signs

The following signs may appear in the onset of angina:

(1) Anxiety, pale, sweating, increased blood pressure, and increased heart rate.

(2) The first heart sound (S1) of the apex is weakened, and an enhanced fourth heart sound (S4) may appear. If the heart rate exceeds 100 beats/min, the fourth heart sound is galloping, reflecting a decrease in ventricular compliance; There is a third heart sound (S3) that is hyperthyroidism. If the heart rate exceeds 100 beats/min, it means early diastolic galloping, reflecting left systolic dysfunction.

(3) accompanied by papillary muscle dysfunction, suggesting acute ischemia of the papillary muscles, temporary mitral regurgitation may occur, in the apex of the apex of the systolic and systolic and/or contraction, late murmur, The above-mentioned clicks and systolic murmurs may have a variable loudness during the onset of angina pectoris, and may be alleviated or disappeared after the relief of angina pectoris.

3. Grading of angina

When patients undergo PTCA or coronary artery bypass grafting (CABG), angina pectoris is a clinically important consideration. Grade III and IV angina, such as drug therapy, should be coronary angiography to determine PTCA or coronary artery bypass grafting (CABG). ), angina pectoris III, grade IV with hypertension, history of myocardial infarction, resting ECG ST segment down to high-risk group, 6-year mortality rate of 40%, no such risk is 8%, indicating that angina pectoris has a certain reference value for prognosis .

In 1972, the Canadian Cardiovascular Association graded according to the amount of activity that induced angina pectoris, which is more suitable for clinical application, and is helpful for assessing the condition and is adopted internationally.

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

Level II: Daily physical activity is restricted, and it is more obvious after a meal, when the cold wind is in a hurry.

Level III: Daily physical activity is significantly limited. Under normal conditions, walking one block or the next level at a normal speed can cause angina pectoris.

Grade IV: Slight activity can cause angina and even attack at rest.

Elderly stable angina check

Cholesterol and triacylglycerol are elevated or normal, or have abnormal lipid metabolism, normal white blood cells and erythrocyte sedimentation rate, myocardial enzymes and troponin, and myosin are normal.

1. Electrocardiogram (ECG) Electrocardiogram is the most common method for detecting myocardial ischemia and diagnosing angina. Commonly used resting electrocardiogram, dynamic electrocardiogram (Holter monitoring) and load electrocardiogram.

(1) resting electrocardiogram: patients with typical angina have a normal resting electrocardiogram of 50% to 83%. The ECG changes that may be seen are: ST-T changes, QRS wave abnormalities, abnormal Q waves, bundle branch block and various Arrhythmia and so on.

Abnormalities (Q-wave width >0.04s, deep 1/4R) suggest that there have been previous myocardial infarctions, some of which may have no corresponding symptoms, infarct Q waves may or may not be associated with ST-T changes, in addition, individual angina attacks occur one The abnormal abnormal Q wave, the termination of the attack, the Q wave disappears.

The most common electrocardiographic abnormalities in elderly patients are non-specific ST-T changes, lack of specificity, and poor reliability in diagnosing myocardial ischemia. In the onset of angina pectoris, most patients may have ST-segment changes due to transient myocardial ischemia. In the R-based lead, the ST-segment horizontal or down-slope type is 0.1mV, and some patients only show T-wave inversion, or the original T-wave inversion is T-wave is erect (pseudo-improvement), due to the room Wall movement disorder causes angina pectoris and recovers rapidly after remission. This dynamic change of electrocardiogram has a higher price for the diagnosis of myocardial ischemia.

Complete left bundle branch block (CLBBB) suggests extensive coronary lesions and left ventricular dysfunction.

Left anterior branch block and left posterior branch block can be seen in coronary heart disease, left ventricular hypertrophy and cardiac position change, which is found to be diagnostic in the onset of angina pectoris.

The QRS wave is short-lived, and the QRS wave low voltage is a very sensitive indicator for diagnosing myocardial ischemia and has a high diagnostic value.

However, there are also a few patients who have no ECG changes at the time of onset, so the diagnosis of angina can not be ruled out by the normal electrocardiogram when chest pain occurs.

(2) Dynamic electrocardiogram (Holter monitoring):

Positive standard: ST segment is horizontal or down-sloping (0.08s after J point), the pressure is 0.1mV, duration is 1min, and the next ST-segment depression should appear after the previous ST-segment depression returns to baseline for at least 1min. Up-slope ST segment, J-point shift and T-wave change can not be used as indicators of myocardial ischemia. Continuous monitoring by Holter for 24 to 48 hours can not only record the daily activities of patients, but also the heart of myocardial ischemia during rest or sleep. Electrical changes, and can record the ECG changes of asymptomatic myocardial ischemia, about 75% of the ischemic ST-segment depression in the Holter monitoring of coronary heart disease patients is asymptomatic, asymptomatic myocardial ischemia and The ratio of myocardial ischemic attacks with angina pectoris was 3 to 4:1. Correlation with coronary angiography showed that the positive rate of coronary heart disease detected by dynamic electrocardiography was 80%, and the false positive rate was 13%. Patients can not be tested for exercise due to various reasons, Holter monitoring has a certain diagnostic value.

(3) Load ECG exercise test: Those who have no change in resting ECG can do this test. At present, multi-level treadmill or treadmill exercise test is used. The result is judged: positive standard:

1 After the exercise and/or exercise, the ST segment is horizontal or down-sloping (0.08s after J point) and the pressure is 0.1mV; or ST segment is horizontally elevated 0.1mV;

2ST segment depression with ventricular arrhythmia, such as frequent ventricular premature contraction (ventricular early), paired room early, multi-source room early or short ventricular tachycardia;

3U wave inversion;

4 exercise causes labor hypotension, systolic blood pressure decreased 10mmHg;

5 typical angina pectoris occurred in exercise, it is currently believed that only when coronary atherosclerosis, causing coronary artery stenosis diameter 50%, the exercise test produces ECG ischemic changes, according to a large number of ECG exercise test and coronary angiography (CAG) comparative study results, the sensitivity of ECG exercise test in patients with coronary artery single-vessel disease is 37% to 60%, the lesion of 2 branches is 69%, and the left main or 3 lesions are 86%-100%. The positive rate of ECG test is high, and the gyroscopic disease is prone to false negative; the same rate of proximal stenosis of the same coronary artery lesion is higher than that of distal stenosis; although the coronary artery is severely narrow, if there is sufficient side The circulatory cycle is established, and the exercise test can be negative. In addition, the above ST changes, such as the low exercise volume in patients with exertional angina pectoris (the Bruce program level 1 exercise amount in the treadmill exercise test, METS 5.0), if there is a multi-lead ST segment severe depression (ST segment level or down-sloping depression >0.2 mV) and/or blood pressure drop, suggesting that there is a left coronary artery or three coronary artery lesions, which is important for evaluating the treatment and prognosis of patients, coronary heart disease People can express myocardial ischemia at rest, and the myocardial oxygen consumption increases during exercise. When the coronary reserve is exceeded, it can lead to myocardial ischemia. Therefore, exercise ECG is helpful for the diagnosis of coronary heart disease. Indications: According to 1990, the United States The criteria for exercise testing recommended by the Heart Association and the American College of Cardiology (AHA/ACC) are:

1 to determine the diagnosis of coronary heart disease;

2 differential diagnosis of chest pain;

3 early detection of occult coronary heart disease;

4 determine the arrhythmia associated with exercise;

5 evaluation of cardiac function;

6 evaluation of coronary heart disease treatment effects (drugs, PTCA, CABG, etc.);

7 evaluate the prognosis of patients with myocardial infarction;

8 guide the patient's recovery.

Contraindications: With the increase of clinical research fields, the renewal of treatment methods and the accumulation of experience, the application range of exercise electrocardiogram (EET) has been broadened, and the taboo indications have been relaxed. Recently, the absolute contraindications in the US EET Guide are:

Acute myocardial infarction within 12 days;

2 unstable angina pectoris uncontrolled by the drug;

3 uncontrolled arrhythmias that produce symptoms or hemodynamic disorders;

4 severe aortic stenosis;

5 uncontrolled symptoms of obvious heart failure;

6 acute pulmonary thrombosis or infarction;

7 acute myocarditis or pericarditis;

8 acute aortic dissection.

End of exercise: Symptom restriction and heart rate restriction in active plate termination (currently used to achieve 85% to 90% of the expected maximum heart rate), the absolute termination indications defined in the EET Guidelines are

1 systolic blood pressure drops 1.33kPa;

2 moderate to severe angina;

3 malignant nervous system symptoms, such as syncope;

4 low perfusion, such as bun, pale;

5 persistent ventricular tachycardia;

6ST segment elevation is 1.0mV.

2. Ultrasound ECG

(1) Two-dimensional echocardiography (2DE) exercise test: Test method: for those with normal wall contraction movement at rest, according to the active plate test of the Balke program, immediately after exercise (1~2min) for 2DE, The criteria for detecting coronary heart disease (CHD) were positive for transient wall motion abnormalities:

1 In the onset of angina pectoris or exercise test, the amplitude of ventricular wall contraction movement in the ischemic area is reduced, disappeared or even reversed (contradictory movement), of which reduction is most common.

2 Ultrasound Doppler mitral valve blood flow spectrum, showing end-diastolic spectral amplitude (A peak) > early diastolic spectrum amplitude (E peak), E / A ratio <1.0 (normal E / A ratio > 1.0), Prompt left ventricular compliance decreased.

3 Left ventricular ejection fraction (EF) did not increase during exercise, suggesting that left ventricular pump function was reduced. The sensitivity of 2DE exercise test to coronary heart disease (CHD) diagnosis was 76% on average, and the average specificity was 86%, compared with ECG exercise test. High sensitivity.

(2) Drug load: The elderly patients or those who have no exercise ability can not complete the rated exercise amount, or the exercise-induced respiratory acceleration affects the image quality. The commonly used drugs are dipyridamole, dobutamine and adenosine. The sensitivity of dobutamine is higher than that of dipyridamole, but the specificity of the three drug loads is similar, and the clinical application of dobutamine is more than that of dipyridamole.

(3) myocardial contrast ultrasonography (MCE): also known as ultrasound myocardial angiography, the Department of Cardiology of Zhujiang Hospital has successfully developed an acoustic contrast contrast agent, a fluorocarbon gas glycoprotein microbubble (C3F8-glycoprotein) Based on the success of animal experiments, it has been initially applied in clinical practice. After 12 patients were intravenously injected with new contrast (0.01ml/kg), satisfactory results were obtained: normal myocardial visually distinct ultrasound contrast Enhancement; myocardial in the ischemic area showed sparse area of microbubble contrast agent; myocardial necrosis showed segmental filling defect, 1 case of female with ECG was complete left bundle branch block, normal coronary angiography, ultrasound myocardial angiography showed The anterior septal segment was filled with defects, and then the myocardial perfusion imaging (ECT) confirmed that there was a filling defect in the same segment of the anterior septum. All patients with new contrast agent had no obvious side effects, and there was no change in ECG and blood pressure monitoring.

3. Radionuclide myocardial perfusion imaging (ECT) Radionuclide myocardial perfusion imaging has two kinds of resting myocardial perfusion imaging and load test, the latter is divided into exercise load test and drug load test, foreign scholars believe that radionuclide The myocardial perfusion imaging load test is an accurate, sensitive and non-invasive primary test method. The indications are:

1 diagnosis of the cause of chest pain;

2 myocardial ischemic site, extent and extent assessment;

3 to understand the myocardial blood supply before and after CABG or PTCA;

4 to determine the prognosis of coronary heart disease, the clinically used radionuclide is 201IL or 99mTc-MIBI for exercise stress test, normal myocardial imaging is uniform, myocardial coronary blood flow in the ischemic or infarcted area is reduced and radioactive release area occurs Defective area, radionuclide exercise load heart

Muscle perfusion imaging is of great value in the diagnosis of coronary heart disease. Compared with ECG exercise stress test, it has higher sensitivity and specificity, especially for women. A multicenter study including 1042 SPECT myocardial imaging exercise tests. The data showed that the total sensitivity of diagnosis of coronary heart disease was 90%, and the detection rate of one, two and three coronary lesions was 83%, 93% and 95%.

The commonly used drugs for myocardial perfusion imaging of radionuclide drug loading test are dipyridamole, dobutamine and adenosine. The elderly have exercise load due to pulmonary infection, severe myocardial ischemia, lack of exercise and general condition. The application of the test is limited. The drug load radionuclide test is helpful to test the myocardial perfusion of the above patients. He Zuoxiang et al. observed the diagnostic value of 21 cases of dobutamine 201TL three-dimensional myocardial imaging in coronary heart disease in 1996. %, sensitivity 96%.

4. Coronary angiography (CAG) and ventricular angiography The above medical history, clinical symptoms and non-invasive methods are of great value in the diagnosis and evaluation of coronary heart disease. However, the diagnosis of coronary heart disease and coronary stenosis Accurate judgment of location, morphology, severity and prognosis still requires coronary angiography. Does coronary angiography require coronary revascularization (including PTCA, rotary and stent implantation, and CABG)? The essential primary means is that coronary angiography is not required for patients with coronary heart disease, but it is necessary to do this in the following situations:

(1) Clinical symptoms, non-invasive examination methods can not be sure whether there is coronary heart disease, coronary angiography can confirm the diagnosis.

(2) Clinical symptoms or non-invasive examination methods suggest that there is no certain coronary heart disease, coronary angiography can confirm the diagnosis.

(3) The symptoms of angina pectoris are heavier, but the medical treatment is not satisfactory, affecting people living in daily life.

The purpose of coronary angiography is to select patients for percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). A comparative study of clinical and coronary angiography has deepened the understanding of coronary heart disease:

1 The relationship between the number of coronary artery lesions and exertional angina pectoris: severe exertional angina pectoris (grade angina grade III, grade IV), with left main stem lesions or multi-vessel lesions more common.

2 The incidence of labor angina was 1 and 2, and the incidence of 3 lesions was about the same, but the reports were different. Domestic reports reported that there were more single lesions (36% to 48.4%) and two of the three lesions.

3 left main lesions reported domestic reports 7% to 14%, foreign reports 5% to 10%.

4 About 10% of patients with angina pectoris have normal or no significant coronary angiography. Some of the ergometrine tests are positive for coronary artery spasm. The ergometrine test may be caused by small coronary artery diastolic dysfunction, such as syndrome X. Left ventricular angiography: is the main method to evaluate left ventricular function, can calculate EF value, find local wall motion abnormalities (low movement, no movement, contradictory movement), is of great value for the selection of patients for revascularization.

Safety of coronary angiography: A large number of data prove that this method is safe, with a mortality rate of 0.1% to 0.45%, a combined myocardial infarction of 0.61%, and a blood test embolization complication of 0.23%.

Diagnosis and identification of stable angina in the elderly

Diagnostic criteria

The diagnosis of stable angina is mainly based on consultation, which can not be replaced by any other diagnostic methods. If there are typical symptoms, the diagnosis of angina can be established, because labor-type angina can also be seen in other diseases such as hypertrophic cardiomyopathy, aortic valve Stenosis, etc., should pay attention to the diagnosis of the primary disease, after the exclusion of other diseases, it can be considered that labor angina is caused by coronary heart disease.

Stable angina should be distinguished from the first-onset angina pectoris. The main difference between the two is that the latter's onset is within 1 month, and there is a tendency to aggravate the episode. The symptoms of angina can be less serious, labor angina and spontaneous angina. Coexistence is not uncommon, mainly with angina pectoris, but sometimes angina pectoris has nothing to do with labor. This type should be diagnosed as mixed angina.

The distinguishing point between stable angina pectoris and variant angina pectoris is that the latter has no relationship with the degree of activity and emotion; the symptoms are heavier and last longer, and the rest can not relieve the pain; the ST-segment elevation occurs during the onset of angina pectoris, and the ST segment recovers after the episode normal.

Differential diagnosis

1. Esophageal diseases are common with reflux esophagitis, esophageal hiatus hernia and esophageal fistula, can cause chest pain, easy to be confused with angina pectoris, according to the history of these diseases, the characteristics of chest pain, chest pain and diet, combined with barium meal or gastroscope Checking is not difficult to make a diagnosis.

2. Cholecystitis often starts suddenly, the pain is mostly in the upper abdomen, more intense, accompanied by fever, leukocytosis, etc., abdominal B-ultrasound can be clearly diagnosed.

3. The location of acute myocardial infarction pain, the same nature, but severe chest pain, long duration, generally > 30min, combined with medical history, dynamic observation of ECG, serum enzymology is not difficult to distinguish with angina.

4. The main symptoms of patients with acute pulmonary infarction are dyspnea, accompanied by chest pain, but chest pain is aggravated during inhalation. Auscultation can be heard and pleural friction sound. X-ray chest X-ray is helpful for diagnosis.

5. The chest wall disease includes costal cartilage inflammation, chest wall contusion, pectoralis major muscle pain caused by influenza virus, and herpes zoster.

6. Cervical or thoracic osteoarthrosis can cause severe chest pain when the spinal dorsal root is involved, as well as cervical ribs. Left shoulder and shoulder and shoulder inflammation can produce symptoms similar to angina.

7. Chest pain caused by non-ischemic angina such as pericarditis, cardiomyopathy, mitral valve prolapse, mitral or active valve disease.

For the symptoms of chest pain ambiguity, can not be sure whether it is angina, should further ECG load test, echocardiogram load test, radionuclide and other tests, if necessary, coronary angiography (CAG) check to confirm the diagnosis.

According to the degree of coronary artery stenosis, the extent and the morphological characteristics of the lesion, the appropriate patient should be selected as PTCA or CABG. When the CAG result of some patients with coronary heart disease is normal, and the MCE or ECT has filling defect, the microtubule lesion should be considered. The measurement of coronary endothelial cell function is of great significance.

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