The age of onset of coronary heart disease is decreasing, and middle-aged people need to pay special attention to coronary heart disease, including myocardial ischemia and acute myocardial infarction two processes, some patients can usually be asymptomatic.
Coronary heart disease is a treatable disease, and it is likened to a “landmine” because it is dangerous and treatable. The basic feature of life is metabolism, which depends on the heart beating constantly to deliver fresh blood rich in nutrients and oxygen to all organs and tissues of the body. As the organ that performs the pumping function, the heart also needs fresh blood and oxygen to maintain its metabolism and function. However, over the long evolution of life, the human heart’s own blood supply system, the coronary arteries, has become quite fragile compared to this extremely important pumping function of the heart. Coronary atherosclerotic heart disease (CHD) is the main cause of disorders of the heart’s own blood supply, and it includes both myocardial ischemia and acute myocardial infarction (AMI) processes. The former refers to partial blockage of the vascular lumen caused by atherosclerotic plaque, resulting in a relative or absolute shortage of blood supply to the myocardium, causing transient and reversible myocardial ischemia and angina, etc. Some patients can be asymptomatic; AMI refers to prolonged severe ischemia and hypoxia of the myocardium to the point of irreversible myocardial necrosis. Coronary heart disease directly threatens people’s health and even life from two aspects: angina pectoris and myocardial infarction lead to cardiac insufficiency, heart failure can seriously reduce the patient’s quality of life, cardiogenic shock often causes death; ischemic myocardium often affects the normal beating rhythm of the heart leading to ventricular tachycardia, ventricular fibrillation and other malignant, stubborn, directly life-threatening arrhythmias.
At present, the incidence of coronary heart disease in China is rising sharply, and the age of onset is decreasing, with some middle-aged and powerful people entering the emergency room because of AMI. There are even tragic cases of death before reaching the emergency room. The World Health Organization estimates that by about 2020, China and other developing countries will be at the peak of the coronary heart disease “epidemic”.
Coronary heart disease is a treatable disease. Many doctors liken coronary heart disease to a ‘mine’ buried in the patient’s body, which has two meanings: first, the danger; do not know when the patient will step on this ‘mine’, once stepped on this “mine First, the danger; not knowing when the patient will step on this “mine”, once stepped on this “mine”, that is, AMI or sudden death, the tragedy is often irreversible; second, treatable: modern treatments for coronary heart disease can successfully exclude this “mine” and remove its threat to the patient.
Correct drug therapy, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are the three main ideas of modern treatment for coronary artery disease; as an important complement to these three treatments, laser myocardial revascularization (TMR or PMR) provides effective symptom relief for some patients with refractory angina. 60-70% of patients with coronary artery disease present with Episodic chest pain as a manifestation, characterized by
Location: mainly asymmetric pain behind the sternum, located in the upper middle part of the body, which can be large or small in extent with unclear borders.
Triggers: With the exception of a few variant angina pectoris, chest pain usually arises during physical activity or emotional stress, i.e., when the oxygen demand of the myocardium increases. This pain usually occurs at the time of physical activity or emotional excitement rather than subsequently. A small percentage of patients with coronary artery disease may present with toothache, pharyngitis, or headache, but this pain is generally associated with physical activity.
Nature: Typical coronary heart disease chest pain is usually a feeling of pressure and urgency behind the sternum, occasionally a feeling of near death or fear, and usually not a pinprick or knife-like sensation.
Radiation: In some patients with coronary artery disease, there is a drilling-like dull pain in the left scapula along with discomfort in the precordial region, forearm internal w division fit, and numbness or dull pain in the little finger and ring finger.
Duration: Chest pain usually lasts only 3 to 5 minutes and disappears naturally after stopping activities or containing nitroglycerin under the tongue for a few minutes. Pain that often lasts more than 20 minutes or slows down only after 20 minutes of containing the drug is generally not angina pectoris.
Men and postmenopausal female patients with episodes of chest pain with the above characteristics suggest that there may be a “landmine” of coronary heart disease in the body, and should immediately see a cardiovascular specialist for some necessary ancillary tests to clarify the diagnosis.
The right medication can effectively relieve angina, improve the quality of life and prolong the patient’s life, and is necessary for the success of the following treatments. Several classes of drugs that are effective or beneficial in the treatment of coronary artery disease are
Aspirin: This is an effective and beneficial drug for the treatment of coronary heart disease that is proven by many international and domestic experts, scientific and large-scale trials, inexpensive, and can greatly reduce the incidence of coronary heart disease and reinfarction, and prolong the life of patients.
Beta-blockers: This is also a proven effective and beneficial drug that is indispensable in the modern treatment of coronary artery disease.
Calcium antagonists: Effective in relieving angina pectoris. In patients with coronary artery disease with cardiac insufficiency, long-acting preparations of dihydropyridines are currently advocated instead of short-acting preparations.
Nitrates: They can effectively relieve angina and have no adverse effect on the long-term prognosis of coronary artery disease.
In addition to the above drugs, anti-platelet drugs such as Ralliadex, anti-thrombotic drugs heparin, other plant drugs, lipid-lowering drugs, converting enzyme inhibitors in the treatment of coronary heart disease occupy an extremely important position.
One of the modern “mine” means: thrombolytic therapy
Patients who usually have episodes of chest pain, if there is severe and persistent chest pain for more than 20 minutes, and sublingual nitroglycerin does not relieve, the possibility of AMI should be highly suspected, and the patient’s family should call 120 emergency number or send the patient to the hospital immediately. After the doctor makes the diagnosis of acute Q-wave myocardial infarction based on the patient’s clinical presentation, the dynamic evolution of the ECG, or the dynamic and serial changes of myocardial damage markers, thrombolytic therapy should be performed immediately (for non-Q-wave infarction, thrombolytic therapy is not performed). Modern pathology has confirmed that acute occlusion of the vascular lumen caused by acute formation of thrombus on the basis of coronary atherosclerosis, resulting in interruption of blood flow in the coronary arteries, is the pathological basis of AMI. Thrombolytic therapy is the intravenous infusion of urokinase, streptokinase and other thrombolytic drugs to open the blood vessels and restore myocardial perfusion. Since its emergence in the mid-1980s, this method has established its position in saving AMI, and is one of the major advances in the history of AMI treatment, and has been popularized to all primary hospitals in China, with rapid efficacy, high safety and simplicity, greatly shortening the patient’s hospitalization time, reducing medical costs, lowering mortality and improving the patient’s quality of life. This treatment is suitable for patients who arrive at the hospital within 12 hours after the onset of the disease, preferably within 6 hours, and its success rate is about 75%. The earlier the treatment is received after the onset of the disease, the more effective it is. Thrombolysis within 1 hour of onset can save 35 more lives per 1000 patients, while thrombolysis within 7-12 hours of onset can save only 16 more lives per 1000 patients. Therefore, time is heart muscle and time is life!
The second means of modern mine clearance: percutaneous transluminal coronary angioplasty (PTCA)
Percutaneous transluminal coronary angioplasty (PTCA) is an intermediate human treatment for coronary artery disease developed in recent years by using high-tech technology, which is applicable to the treatment of all stages of coronary artery disease. A special small catheter is inserted into the arterial vessels of the patient’s extremities to reach the opening of the coronary artery under the guidance of X-ray, and then a coronary angiogram is taken to clarify the location, nature and severity of the lesion. If the effect of balloon dilation alone is not satisfactory, an alloy stent with laser polishing and cutting is usually delivered to the lesion to support the vessel and achieve adequate opening of the vessel. For some vessels that are not suitable for simple PTCA with stent implantation, measures such as directional coronary intimal plaque spinning (DCA) can also be used.
PTCA can be divided into emergency PTCA and non-emergency elective PTCA according to the urgency of the disease; the former is mainly applied to patients with unstable angina who have failed in the early treatment of AMI and drug therapy; the latter is mainly used for patients with stable coronary artery disease. Since the introduction of this technology in China in the 1980s, it has developed rapidly, especially emergency PTCA is the most direct, rapid and reliable way to save AMI patients today. Our center has listed PTCA as the routine method of choice to save AMI, and with the aid of advanced technology of intra-aortic balloon counterpulsation, we have successfully saved more than 600 patients with a success rate of more than 98%. Compared with coronary artery bypass grafting, PTCA has the advantages of no chest opening, no general anesthesia, and minimal trauma to the patient. Its degree of hemodynamic reconstruction is much higher than that of thrombolytic therapy, but for some patients its efficacy is not as good as that of coronary artery bypass grafting, and there is a possibility of postoperative restenosis of about l5%.
Coronary artery bypass grafting (CABG) is the third modern means of “mine clearance”.
Coronary artery bypass grafting (CABG) is also known as “coronary artery bypass grafting”. It is performed by taking a vein or artery from the patient that does not affect physiological function, connecting one end to the root of the aorta and the other end to the distal end of the coronary artery lesion, bypassing the diseased portion of the coronary artery and acting as a “bridge” to the distal myocardium.
CABG not only solves the problems faced by drug therapy and PTCA in the treatment of coronary artery disease, such as lesions at branches, multiple branches, and unprotected left main artery lesions, but is also the most complete and thorough way to reconstruct blood flow. Patients can return to normal work 1-2 months after bypass surgery, and the elimination rate of their early angina symptoms is as high as 85%-95%. More than 65% of patients are angina-free for 5 years after surgery, with a 5-year survival rate of 93% and a 10-year survival rate of 80%. Even for those who have lesions in 3 coronary arteries with impaired cardiac function, the 7-year survival rate can reach 90%, compared to 37% for those who receive drug therapy alone. In the past, the saphenous vein was used as the bridge vessel, but with the improvement and development of surgical techniques and instruments, surgeons are now more willing to use arteries with higher long-term patency and survival rates and better prognosis, such as the internal mammary artery and the flexural artery, as the bridge vessel.
The procedure generally requires general anesthesia, extracorporeal circulation and temporary cardiac arrest, which is the main concern of patients about this treatment. In fact, in 1999
Russian President Boris Yeltsin underwent saphenous vein bypass surgery in November 1999. As the president of a major country with a “nuclear button” in his hand and the safety of the world at stake, he gladly underwent the procedure and “easily” resigned at the beginning of the year, which eloquently illustrates that the procedure has been developed to the highest level. Last year alone, our center completed more than 200 cases of coronary artery bypass grafting, with a success rate of more than 98%. Now we have taken the lead in carrying out minimally invasive coronary artery bypass grafting with small incisions and non-stop heartbeat, and the results are satisfactory from more than 10 completed cases.
Modern mine clearance aid: laser myocardial revascularization (TMR or PMR)
In spite of the above three methods of mine clearance, some patients with severe angina pectoris still have little success due to severe diffuse lesions, small vessel lesions, restenosis and thrombosis of the graft bridge. The increasingly sophisticated laser myocardial revascularization (TMR, open-heart) and the emerging percutaneous intracavitary laser myocardial revascularization (PMR, open-heart) offer a new treatment option for these patients.
The principle behind TMR or PMR is that reptilian hearts do not have coronary arteries and they rely on the pressure step difference between the systolic and diastolic phases of the heart to press blood into the extensive sinusoidal gaps between the myocardium to perfuse the myocardium with blood. This gap also exists in the human fetal heart, except that after birth it no longer communicates directly with the cardiac chambers or coronary arteries. So, is it possible to use laser energy to make some tunnels in the ischemic myocardium and use these tunnels and the sinus gaps that communicate with the laser tunnels to perfuse the ischemic myocardium with blood through the pressure difference between systolic and diastolic periods? This was the principle of TMR or PMR as originally envisioned, but current research suggests that the principle is much more complex than originally thought.
Satisfactory results are currently considered to be achieved in the following cases: 1. Severe angina or unstable angina. 2. PTCA or CABG cannot be performed for anatomic or physiologic reasons. 3. There must be objective preoperative evidence that the myocardium in the area of ligation is not yet necrotic. 4. Complete hemodialysis cannot be achieved with PTCA or CABG. 5. Bridge stenosis after CABG or PTCA after 6. The patient has good cardiac function.
Since 1992, the US FDA has designated several cardiac centers to observe the efficacy of TMR, and for more than 8 years, the results of nearly 8,000 TMR cases performed in more than 100 cardiac centers worldwide show that TMR is effective and safe: compared with conventional treatment, patients’ angina is significantly relieved after TMR, and patients’ angina level is significantly reduced during follow-up; the results of exercise stress test at discharge and during follow-up are very good. The tolerance time of exercise stress test was significantly longer at discharge and at follow-up; the proportion of myocardial perfusion in the endocardial epicardium was significantly increased. While TMR was previously used as an adjunct to CABG and as a treatment option for patients with severe refractory angina, it is now being used clinically as a complementary hemodynamic reconstructive tool to ppCA and CABG.
PMR is emerging worldwide with no significant difference in efficacy from TMR before tears. Although the long-term efficacy of TMR and PMR is still controversial, the recent effect of TMR and PMR on “effectively relieving angina pectoris, improving patient quality of life, and reducing readmission rates” has been confirmed from the more than 10 cases of TMR and PMR we performed.