Coronary heart disease refers to the relative or absolute ischemia of the myocardium caused by coronary atherosclerosis and functional changes in the coronary arteries (such as spasm). The full name of the disease is coronary heart disease, or coronary atherosclerotic heart disease, or coronary heart disease, also known as ischemic heart disease.
In China, with the improvement of people’s living standard, the incidence of coronary heart disease is increasing year by year, becoming the second leading cause of death after malignant tumor. 1990 statistics show that the first cause of death in China’s cities is cardiovascular disease. The mortality rate was 115.40/100,000, while in rural areas it was 123.68/100,000. Coronary heart disease accounts for the largest proportion of all cardiovascular causes of death in urban areas.
As recommended by the World Health Organization, coronary heart disease is divided into the following types: angina pectoris type. Myocardial infarction type. Arrhythmia and myocardial sclerosis. The insidious type and the sudden death type. The definite diagnosis should be based on clinical symptoms, combined with physical examination. Electrocardiogram. Cardiac ultrasound and coronary angiography can be made.
I. Angina pectoris
Angina pectoris is a clinical syndrome caused by insufficient coronary artery blood supply, acute and temporary ischemia and hypoxia of the myocardium.
Diagnostic points]
(a) Typical angina is characterized by episodic chest pain as the main clinical manifestation. The pain site is mainly in the upper or middle part of the sternal body and can spread to the precordial area, with a palm-sized range, or even across the anterior chest, the boundaries are not very clear. It often radiates to the left shoulder, the left inner arm up to the ring finger and little finger, or to the neck, pharynx or jaw.
(B) The nature of pain is often compressive, hairy or constricting, and may also have a burning sensation, but not sharp, unlike pinprick or stab-like pain, occasionally accompanied by a fear of dying. Patients often unconsciously stop their original activities during an attack until the symptoms are relieved.
(c) Pain is often triggered by physical labor, emotional excitement (such as anger, anxiety, overexcitement, etc.), satiety, cold, smoking, tachycardia, shock, etc. Pain occurs at the time of exertion or excitement, but not after exertion.
(d) The pain lasts for 3 to 5 min, with the longest duration not exceeding 15 min, and is usually relieved after stopping the original symptom-triggering activity, and sublingual nitroglycerin can make it disappear within a few minutes. It can be a few days or weeks of seizures 1 cross, but also 1d within a multi-flash seizures.
(E) Usually there are no abnormal signs. Angina attack commonly accelerated heart rate, blood pressure, expression anxiety, cold skin or sweating, and sometimes the fourth or third heart sound gallop rhythm.
(F) Auxiliary examinations.
1.X-ray examination: no abnormal heart or see enlarged heart shadow, lung congestion, etc.
2, ECG examination.
(1) About half of them are in the normal range at rest.
(2) The majority of patients may have temporary myocardial ischemia-induced ST-segment depression during angina attack, and sometimes T-wave inversion, which may become upright during the attack in patients with persistent T-wave inversion (so-called “pseudo-normalization”).
(3) Electrocardiographic stress test.
(1) to multiply the second-step exercise in the R wave dominant leads, ST segment horizontal or downward sloping type depression of 0.05mV or more for 2min or ST arch dorsal upward type elevation of more than 0.2mV as positive criteria, such as the occurrence of angina pectoris at the same time, the diagnosis is more significant;
②Pedal and pedal exercise, mainly with ST segment horizontal type or downward sloping type depression ≥ 0.1mV (from J point) lasting 0.08s as positive criteria.
3. Coronary angiography is of greater diagnostic significance and can detect the site of stenotic lesions in each branch of the artery and estimate their extent.
(VII) Clinical characteristics of each type of angina pectoris.
1, exertional angina, characterized by pain induced by physical exertion, emotional excitement or other conditions sufficient to increase myocardial oxygen demand, disappears rapidly after rest or sublingual nitroglycerin.
2, spontaneous angina pectoris, characterized by the occurrence of pain and myocardial oxygen demand increased no obvious relationship, the pain is heavier, the time frame is longer, not easily relieved by the use of nitroglycerin.
3, mixed angina, which is characterized by the patient both when the increase in myocardial oxygen demand angina, but also when the myocardial oxygen demand does not significantly increase angina.
Treatment】
(a) Treatment of the attack period.
1.Rest.
Rest immediately when the attack occurs, and generally the patient’s symptoms can be eliminated after stopping the activity.
2, drug treatment.
(1) Nitroglycerin 0.3-0.6mg, sublingual, 1~2min will start to take effect, and the effect will disappear after about 0.5h.
(2) Isosorbide dinitrate 5~10mg, sublingual, 2~5min to take effect, the effect will be maintained for 2~3h.
(3) Isosorbide nitrite, 0.2ml per ampoule, wrapped in a handkerchief and cracked, immediately covered in the nose and inhaled, the effect is fast and short, starting within 10-15s, disappearing in a few minutes.
3. Inhale oxygen if necessary.
(B) Treatment in remission.
1.Avoid various triggering factors.
Regulate diet, abstain from smoking and alcohol, reduce mental burden, maintain appropriate physical activity and exercise (walking, tai chi), and pay attention to the combination of work and rest.
2, nitrate preparations.
(1) Isosorbide dinitrate 5~10mg, orally, 3 times/d.
(2) Pentaerythritol tetranitrate 10～30mg, orally, 3～4 times/d.
(3) Long-acting nitroglycerin tablets 2.5mg, taken once every 8h; 2% nitroglycerin ointment or rubber paste (containing 5~10mg) applied or pasted on the skin of chest or upper arm and slowly absorbed, can prevent prone type angina attack.
3, beta-blockers.
(1) 10mg of benzoin, orally, 3-4 times / d, gradually increase the dose to 100 ~ 200mg / d.
(2) Metoprolol 50-100mg, orally, 3 times / d.
(3) Atenolol 25mg, orally, 2 times/d.
4. Calcium channel blocking agents.
(1) Cardiac pain 10～20mg, orally, 3 times/d, also can be used sublingually.
(2) Verapamil 80～160mg, orally, 3 times/d.
(3) Tenel Heart (Diltiazem) 30～90mg, orally, 3 times/d.
(4) Cardiac Detox 15～60mg, orally, 3 times/d.
5. Coronary artery dilators.
(1)Pansentin 25～50mg, orally, 3 times/d.
(2)Pulsatilla 1~2mg, orally, 3 times/d.
(3)Ethylene iodofurone 100-200 times/d, orally, 3 times/d.
(3) Other treatments.
Low molecular dextrose 250～500ml, 1 time/d intravenous drip, 14～30d for 1 course of treatment; hyperbaric oxygen therapy can improve the recalcitrant angina; extracorporeal counterpulsation can increase the blood supply of coronary arteries; for those who also have early heart failure, fast-acting digitalis-type preparations are appropriate.
(iv) Surgical treatment: aortic-coronary artery bypass graft surgery is performed, mainly for angina pectoris that cannot be controlled by medical treatment.
(v) Percutaneous transluminal coronary artery angioplasty (PTCA): it can be used instead of surgical treatment in patients with indications and receive the same effect. The indications are: (i) angina pectoris of longer than 1 year, but making the patient lose health; (ii) preferably 1 coronary artery lesion, and the lesion is proximal; (iii) objective evidence of myocardial ischemia; (iv) the patient preferably has good collateral circulation and left ventricular function.
II. Myocardial infarction
Myocardial infarction is ischemic necrosis of the myocardium. It is caused by a drastic reduction or interruption of coronary blood supply on the basis of coronary artery lesions, resulting in severe and persistent acute ischemia of the corresponding myocardium. It is a serious type of coronary heart disease.
Diagnostic points
(a) Sudden onset of severe and persistent pain in the retrosternal or precordial region, mostly without obvious cause, and often occurs in quiet time, some patients radiate to the jaw, neck, upper back or upper abdomen, rest and nitroglycerin can not be relieved, patients are often irritable, sweating, fear or a sense of imminent death. A small number of patients have no pain and show shock or acute heart failure at the beginning.
(ii) Fever, tachycardia, frequent nausea, emesis and epigastric distention, intestinal distention, and erratic reflux.
(iii) Arrhythmia with ventricular premature beats most common, hypotension and shock; heart failure, mainly acute left ventricular failure, right ventricular myocardial infarction may start with right heart failure manifestation with hypotension.
(iv) The heart borders are enlarged, the heart rate is mostly increased, a few can be slowed down, the first heart sound in the apical region is diminished, the fourth heart sound gallop rhythm, the third heart sound gallop rhythm, rough systolic murmur in the apical region may appear.
(E) Auxiliary examinations.
1.Electrocardiographic examination: pathological Q waves, ST-segment elevation in an arch-back upward, and one-way curve connected with upright T waves appear in the corresponding leads according to their infarct sites.
2.Cardiac vectorogram: there are changes in ORS ring, appearance of ST vector and changes in T ring.
3.Radionuclide examination: it can show the site and scope of myocardial infarction.
4.Laboratory tests.
(1) More white blood cell production and faster erythrocyte sedimentation rate.
(2) Increased serum cardiac enzyme levels.
(1) Creatine phosphokinase is elevated within 6h of onset and returns to normal within 48-72h;
②Glutamic oxalacetic transaminase is high after 6-12 hours of onset, peaks at 24-48 hours, and decreases to normal in 3-6 days;
(③Lactate dehydrogenase grows high after 8-10h of onset, peaks in 2-3d, and lasts 1-2 weeks before returning to normal.
(vi) Complications.
1. Papillary muscle dysfunction or rupture.
① Late systolic karate and loud blowing systolic murmur in the apical region with no diminution or enhancement of the first heart sound;
②Heart failure or pulmonary edema may occur.
2. Heart rupture.
①Often appear within 1 week of onset;
(2) Rupture of the free wall of the ventricle, resulting in sudden death due to acute pericardial tamponade caused by accumulation of blood in the pericardium;
(3) Rupture of the ventricular septum causing perforation, which may result in a loud systolic murmur between the 3rd and 3rd ribs at the left edge of the sternum, often accompanied by tremor, and may cause heart failure and shock and death within a few days.
3. Embolism.
①Embolism of the brain, kidney, spleen or arteries of the extremities occurs 1 to 2 weeks after the onset of the disease;
②Pulmonary artery embolism occurs when the lower extremity vein thrombus is partially dislodged.
4.Ventricular expansion tumor or ventricular wall tumor.
①ST-segment elevation persists for more than 6 months;
②X-ray fluoroscopy shows localized edge protrusion, reduced pulsation or paradoxical pulsation.
5, post-myocardial infarction syndrome: in the myocardial kingland weeks to months after the emergence of recurrent pericarditis, pleurisy or pneumonia.
6.Shoulder-hand syndrome: in the weeks after myocardial infarction appeared in the shoulder and arm straightening, restricted movement and pain.
Treatment
(I) Monitoring and general treatment.
1, rest: bed rest for 2 weeks, the third can be out of bed, the fourth can be indoor walking if there is no discomfort response. The bed rest time should be appropriately extended for those who are seriously ill.
2, oxygen: the first few days intermittent or continuous through the nasal tube mask oxygen.
3, monitoring: electrocardiogram, blood pressure and respiratory monitoring for 5 to 7 d, monitoring pulmonary capillary pressure and venous pressure if necessary.
4.Care: The patient was completely 2-bedded in the 1st week, and all daily life was carried out with the help of nursing staff. Eating should not be too full; keep the large love smooth, such as constipation can give slow laxatives.
(II) relief of pain.
1, pethidine 50 ~ 100m, intramuscular injection; or bar morphine 5 ~ 10mg intradermal injection, if necessary 1 ~ 2h re-injection 1, after every 4 ~ 6h can be repeated application.
2, codeine or poppyine 30 ~ 60m, intramuscular injection or oral.
3.Nitroglycerin 0.3mg or cardiac pain 5-10mg sublingual; or intravenous drip nitroglycerin.
4, pain can not be relieved by the above treatment, artificial hibernation therapy can be used to pethidine 50-100mg, isonezine 25-50mg, hydroergot alkaloids 0.6-0.9mg into 5% grape 500ml intravenous drip, must be closely monitored blood pressure.
(iii) Myocardial reperfusion.
1. Urokinase: 1 million to 1.5 million u in 0.5h (for those within 6h of onset). Take 300mg of aspirin orally before the drip, and 300mg/d thereafter, report 3 d, change to 50mg/d.
2.Streptokinase: After negative skin test, add 750,000u to 100ml of 5 glucose solution intravenously and finish dripping around 0.5h, then give 100,000u every hour for 24h.
3, tissue-type fibrinogen activator: for intravenous or intracoronary injection, the dose is 0.75m/k body weight for 30-120min, the intracoronary dosage is reduced by half.
(iv) Elimination of arrhythmias.
1, immediately after the onset of the disease, intramuscular injection of lidocaine 200-250mg once every 8h for 3 d to prevent ventricular arrhythmias .
2.Once ventricular premature beats or ventricular tachycardia appear, lidocaine 50~100mg should be injected intravenously and repeated every 5~10min until the premature beats disappear or the total amount reaches 300m g, followed by intravenous drip at the rate of 1~3mg/min (lidocaine 100mg should be added to 5% glucose solution 100ml and dripped 1~3ml per minute), after the condition is stabilized, the drip should be changed to slow Heart rhythm 150mg or procaine amide 250-500mg, oral, every 6h 1 time maintenance.
3, slow heart rate can be used atropine 0.5 ~ 1.0mg intramuscular or intravenous injection.
4, II or III degree atrioventricular block, while drug therapy, prepare to place an artificial pacemaker.
5, the occurrence of ventricular fibrillation, as soon as possible using non-synchronous DC defibrillation; ventricular tachycardia drug efficacy is unsatisfactory should also be applied early synchronous DC resuscitation.
6, supraventricular tachyarrhythmia with digitalis, verapamil and other drug therapy can not be controlled, can be considered with synchronous direct current to restore sinus rhythm or artificial pacemaker to do overdrive suppression therapy.
(E) Control of shock.
1.Replenish blood volume: use low molecular dextrose or 5%-10% glucose solution intravenously, the daily infusion volume should not exceed 1000ml, and the infusion speed should not be too fast.
2, application of antihypertensive drugs: blood pressure still does not rise after replenishment of blood volume, can be added to 5% glucose solution dopamine 10 ~ 30mg, m-hydroxylamine 10 ~ 30mg or norepinephrine 0.5 ~ 1 .0mg intravenous drip.
3.Application of vasodilator: After the above treatment, blood pressure still does not rise, and there is peripheral vasoconstriction so that the extremities are cold and cyanosis, can be added in 5% glucose solution 100ml sodium nitroprusside 5 ~ 10mg, nitroglycerin 1mg or phentolamine 10 ~ 20mg intravenous drip.
4. Others: correct acidosis, avoid cerebral ischemia, protect renal function, apply glucocorticoids and cardiac glycosides if necessary, and intra-aortic balloon counterpulsation.
(F) treatment of heart failure: the main thing is to treat acute left heart failure, the application of bar morphine (or pethidine), diuretics and vasodilators, or dobutamine 10μg/kg per minute intravenous drip, after the onset of 24h is appropriate to do without digitalis. Diuretics should be used with caution in the presence of right ventricular infarction.
(vii) Other treatments.
1, to promote myocardial metabolism drugs: vitamin C 3 ~ 4g, coenzyme A 50 ~ 100u, sodium inosinate 200 ~ 600mg, cytochrome C 30mg, vitamin B650 ~ 100mg, etc., added to 5% ~ 10% glucose solution 500ml, slow intravenous drip, 1 time / d, 1 week as a course of treatment.
2, polarization fluid therapy: potassium chloride 1.5g, ordinary insulin 8u added to 10% grape liquid 500ml, intravenous drip 1 ~ 2 times / d. Simplified oral method: glucose 200g 10% potassium chloride 30ml for 1d amount, divided into 3 times oral. Polarization therapy is generally used for 7 to 14d.
3, low molecular dextrose 00ml intravenous drip, 1 time / d, 2 weeks for a course of treatment.
4.Hyaluronidase: first use 150u for intradermal test. If negative, it can be injected intravenously at 500u/kg body weight, and the same dose will be given once in the second and sixth hours after the first dose, and once every 6 hours thereafter for a total of 42 hours.
5.Beta blocker: Apply at the early stage of disease onset. Cardiotrope 5-10mg, orally, 3 times/d; Metoprolol 6.25-25mg, orally, 1~2 times/d.
6, anticoagulation therapy: heparin 50 ~ 75mg intravenous drip, every 6g once, or 100mg deep intramuscular injection, every 8h once, a total of 2d. maintain the clotting time at about 2 times normal (test tube method 20-30min maintenance, the course of treatment for at least 4 weeks.
(H) Management of complications.
1, in case of complication of embolism, anticoagulation therapy or with dissolution of thrombus therapy is available.
2.Ventricular expansion tumor, heart rupture, and severe dysfunction of papillary muscle can be treated surgically.
3, post-myocardial infarction syndrome, shoulder-hand syndrome, available hormone therapy.
(ix) Treatment of recovery period.
After 4-6 weeks of hospitalization, discharge may be considered if the condition is stable. 2-4 months of physical activity exercise, resume partial work as appropriate, but excessive physical labor should be avoided.
(X) Management of right ventricular myocardial infarction.
Slightly different from left ventricular myocardial infarction, it is advisable to expand blood volume, diuretics should not be used, and intravenous infusion of 3-6L can be given within 24h until the hypotension is corrected, in which case hypotension is not corrected available cardiac stimulants.
Chinese medicine and other treatments for coronary heart disease
(a) Chinese medicine treatment: coronary heart disease is divided into two categories of deficiency and reality. But clinically, the deficiency and the real are often seen in each other, and the manifestation is the deficiency and the real. The symptoms are mainly real, such as qi stagnation, blood stasis, phlegm and dampness, paralysis, etc., when the treatment of the symptoms is urgent: the deficiency is mainly real, such as qi and yin deficiency, kidney yang weakness, yang deficiency want to take off, etc., when to cultivate the root as the first. Treatment should be applied flexibly by weighing the deficiency and urgency.
1.Actual evidence.
(1) Chest Yang paralysis: Heart pain is triggered by cold, shortness of breath and stuffiness in the chest. In severe cases, heart pain through the back, back pain through the heart, tongue coating greasy, pulse string slippery. Treatment: Promoting paralysis through Yang. Remedy: Gua Gua Bai Gui Zhi Tang plus or minus.
(2) Stasis in the heart: stabbing pain in the heart and chest, distension and pain in the two hypochondria, shortage of breath, restlessness, petechiae or purple spots on the tongue, stringiness or astringency of the pulse. Treatment: Invigorate blood circulation, resolve blood stasis and regulate liver and Qi. Treatment: Promote blood circulation, resolve blood stasis, and regulate liver and Qi.
(3) Internal obstruction of phlegm and turbidity: chest tightness or pain, obesity, body weight and weakness, thick and greasy moss or turbidity, smooth and solid pulse. Treatment: Aromatize turbidity, regulate the spleen and resolve phlegm. Prescription: Broad Chest Pill or Suhe Xiang Pill to swallow, followed by warm gall bladder soup with addition and reduction.
2. Deficiency evidence.
(1) Qi and Yin deficiency: heart pain, shortage of breath, palpitations, spontaneous sweating, dry mouth with little fluid, red tongue with little coating, weak pulse string or knotted generation. Treatment: Benefit Qi and nourish Yin. Remedy: Add and subtract raw pulse san.
(2) Weakness of kidney yang: heart pain, shortage of breath, palpitations, cold form and limbs, soreness of the waist and knees, pale tongue with white fur, sunken and weak pulse or knotted generation. Treatment: Warming and tonifying kidney yang. Remedy: Jin Kui Kidney Qi Pill with addition and subtraction.
(3) Yang deficiency and descent: heart pain, shortness of breath, profuse sweating, cold extremities, pale face, even fainting, pale tongue, white fur, sinking pulse or knotted generation. Treatment: Returning Yang to fix the deficiency and rescuing it. Remedy: Ginseng and Longmu Tang with reduction.
(B) Acupuncture treatment.
1. Body acupuncture: take Nei Guan, Gong Sun, Xin Yu and Ju Que as the main points. Blood stasis plus diaphragm Yu, blood sea; phlegm congestion plus Taiyuan, Fenglong; Yang deficiency cold condensation heavy with sizzling method; Qi and Yin deficiency plus Yin Qie, Qihai; kidney Yin deficiency plus Taixi; angina pectoris plus Yin Qie, Tanzhong through the breast root; chest tightness plus Ding gas, Tanzhong; arrhythmia plus Qiemen; tachycardia plus interdigitated, hand Sanli; bradycardia plus Su Tongli; edema plus Sanjiao Yu, kidney Yu, water, Yinlingquan; heart Yang storm off plus Baihui 〓 Renzhong, Guan Yuan. Qihai, Shenqu, foot Sanli.
2, sizzling method: take Tanzhong, Tianjing, with moxa suspension sizzling. Suitable for the prevention of angina attacks.
3.Cupping: Group A: Dazhi, Xin Yu, Tanzhong; Group B: Shen Dao, Ju Que, Jue Yin Yu. 2 groups are used alternately.
4.Auricular acupuncture: take heart, Shenmen, sympathetic, subcortical, endocrine and kidney. The auricular pressure pill method can also be used.
5.Head acupuncture: bilateral thoracic area.
6.Electro-acupuncture: heart, danzhong, diaphragm, sympathetic yin, hatched tail, nei guan, tong li, foot san li, tai chong.
7.Laser acupuncture: take points according to body acupuncture, irradiate each point for 3-5 min, 15 times for 1 course of treatment.
8.Patching: take Tanzhong and Neiguan, use Chuanxiong 3g, ice chips 1g, nitroglycerin 1 tablet, finely grind together, make a pill as big as a soybean and use it for Liu blood. Each point paste 1 pill, adhesive tape fixed. Change 1 time daily, 5 times for a course of treatment.
9, acupuncture point injection: take heart Yu, Jueyin Yu, Qimen, Nei Guan, with Danshen injection and Mao Dongqing injection alternately inject the above points, each time choose 1 to 2 points, each point injection 0.5 ~ 1ml. daily or every other day, 10 times for a course of treatment.
(C) buried wire therapy: take heart Yu, Neiguan, buried in sheep intestine wire, 15 d later can be buried again 1 time. It is suitable for those with coronary heart disease arrhythmia.
(iv) Tuina therapy: the patient is seated, and the doctor presses and rubs Lung Yu, Heart Yu, Diaphragm Yu and Neiguan. The patient should feel slightly sore and swollen, and each point should be rubbed for 2 min. If the heart rate is slow and there is a leaky beat, press the soft left side of the sympathetic Yin Yu for 2 to 5 min; if the chest is very tight, press and rub the Tanzhong and both sides of the Zhongfu points for 2 min each.
(E) single experimental formula.
1.Mushroom Ganoderma lucidum 30g, decoction in water; Ganoderma lucidum tincture or Ganoderma lucidum syrup, 5-10ml per oral dose, 3 times/d.
2, Panax ginseng powder 3g, cinnamon powder 1.5g, Angelica sinensis 30g, decoction of Angelica sinensis, brewed with Panax ginseng powder and cinnamon powder, 3 times/d.
3. 30g of thatch root, 15g of safflower, 30g of yujin, 10g of peach kernel, decocted in water.
4.Leek root in appropriate amount, pounded with juice and taken when in pain.
5.Red peony, Chuanxiong, safflower, and sorrel 15g each, Salviae Miltiorrhizae 30g, Eucommiae, Guadua, and Allium 9g each, taken with water decoction.
(F) diet and drinking method.
1. 30-60g of fresh Allium, 2 stems of white onion, 100-150g of white flour, mixed and mixed into boiling water and boiled.
2. 30g of purple-skinned garlic, peeled, put into boiling water for 1min and take out, then take 100g of japonica rice, put into boiling garlic water and cook into porridge, then put the garlic back into the porridge and cook again, take warm in the morning and evening.