Clinical typing and presentation types of coronary heart disease
Regarding the typing of coronary heart disease, the World Health Organization classified the following five types according to their clinical characteristics as early as 1974: i. primary cardiac arrest; ii. angina pectoris (including exertional angina and spontaneous angina); iii. myocardial infarction (including acute myocardial infarction and old myocardial infarction); iv. heart failure in ischemic heart disease; v. arrhythmia. Wang Yunfei, Cardiovascular Disease Specialist, Guangdong Provincial Hospital of Traditional Chinese Medicine
Our country is accordingly divided into five types according to the clinical manifestations of coronary heart disease, namely, one occult coronary heart disease, two angina type coronary heart disease, three myocardial infarction type coronary heart disease, four heart failure and arrhythmia type coronary heart disease, and five sudden death type coronary heart disease. They reflect the location and extent of coronary artery disease, the degree of vascular stenosis, the speed of myocardial ischemia and its degree, and so on. Here we introduce their clinical manifestations one by one.
3==4==1 Occult coronary artery disease
Occult means hidden from view. Occult coronary artery disease means that some patients with coronary artery disease do not feel any discomfort themselves, but only when they are objectively examined with various instruments, there are manifestations of myocardial ischemia, such as an electrocardiogram with normal examination. This is due to patients with mild coronary atherosclerotic lesions or even if they are more severe, but the collateral circulation is established earlier or better, or the patient has a higher threshold of pain tolerance and is insensitive to milder pain sensations.
In occult coronary artery disease, patients do not have obvious symptoms, but this does not mean that they are not at risk. Moreover, the patient’s objective examination does not show any significant resting, dynamic; or stress test ECG shows myocardial ischemic-like coup, such as ST depression and T-wave inversion. The disease still has a serious developmental and evolutionary nature. There is a great potential risk, so early diagnosis and timely treatment should be emphasized and given special attention. Therefore, people over 40 years of age, especially those with smoking, obesity, hyperlipidemia, hypertension, diabetes, etc., should undergo regular comprehensive medical checkups, including blood pressure levels, lipid levels, blood glucose values, electrocardiograms and other routine indicators. More attention should be paid to the short period of electrocardiogram examination in susceptible people, which often has a very important suggestive meaning. According to the results of the focused screening, further examinations such as exercise ECG, 24-hour ambulatory ECG, coronary angiography, radionuclide examination, etc. will be performed. That is, the accuracy of screening for occult coronary artery disease can be improved, and the site and degree of stenosis as well as collateral circulation can be rapidly identified. Continuous recording of dynamic electrocardiogram can show the frequency, severity, duration and dynamic changes of myocardial ischemia, which is a simple and effective method to reveal the cause and pattern of the attack.
Without using words, occult coronary artery disease is a kind of coronary artery disease, which is a milder manifestation, so some scholars also consider it as an early indication of coronary artery disease. However, it is still essentially an inadequate blood supply to the heart muscle caused by coronary atherosclerosis. This shows that occult coronary artery disease also affects the function of the heart and poses a major risk to the normal maintenance of heart function. It can definitely reduce the systolic function of the left ventricle, lower the ejection fraction, and even cause mild failure of the whole heart and abnormal ventricular wall motion. If the disease is not detected and treated in time, there is a high risk of angina pectoris and even myocardial sclerosis, sudden death, arrhythmia and other types of coronary heart disease. Particularly alert to the more likely to evolve into a myocardial infarction without any preliminary symptoms. According to the survey, 20-25% of myocardial infarction is caused by insidious coronary heart disease. Patients do not have any preliminary symptoms at the onset of the disease, and when arrhythmias, heart failure or even shock appear, the condition is already extremely serious. The mortality rate is significantly higher than that of myocardial infarction caused by angina pectoris.
3==4==2 Angina-type coronary heart disease
Angina pectoris is the most common and most common type of coronary heart disease in the clinical manifestations of coronary heart disease.
Angina is a group of clinical syndromes or so-called syndromes caused by acute, sudden and transient coronary artery blood supply insufficiency, resulting in myocardial ischemia and hypoxia, which is a more obvious and direct manifestation of coronary heart disease. The disease is mostly caused by emotional excitement or diet, exertion and other obvious triggers that increase the burden on the heart, mostly occurring in middle-aged and elderly people over 40 years of age, more men than women. The clinical manifestations are varied, mainly the persistent chest pain or chest suffocation, or even pressure-like or tight-binding pain behind the sternum, and mostly radiates to the precordial to and the inner left upper limb, and the patient is often forced to stop activities or work. Generally speaking, it lasts for a few seconds or even a few minutes, not more than 15 minutes, and can be relieved by itself after resting, and in severe cases, it is often relieved by using preparations such as nitroglycerin in the mouth. This evidence is not only seen in coronary artery disease, but also in such diseases as aortic stenosis or incomplete closure, rheumatic coronary arteritis, severe anemia and hyperthyroidism, hypertrophic cardiomyopathy, etc. While excluding these diseases mentioned above, it is not difficult to diagnose coronary angina in general. In addition patients are often accompanied by palpitations, shortness of breath, dyspnea, dizziness, pale face, cold sweat, anxious face and even syncope.
For patients with angina pectoris, once the diagnosis is clear and other causes of angina pectoris are excluded, a careful typing diagnosis must be made. Usually, with reference to the scheme of “Nomenclature and Diagnostic Criteria of Ischemic Heart Disease” of the World Health Organization, the following typing diagnosis is generally made.
3==4==2==1 Exertional angina pectoris
This name was first proposed by Heberden in 1786 and its definition was described in detail. Because of its early introduction, it is also known as classic angina pectoris. The obvious triggers for an attack are physical exertion, emotional excitement, etc., and other obvious short periods of dramatic increase in myocardial oxygen consumption, and the symptoms resolve quickly or disappear quickly after rest or sublingual nitroglycerin. It is further differentiated into the following three types.
3==4==2==1===1 Primary angina.
Patients with no previous history of angina pectoris or myocardial infarction, who present for the first time with angina pectoris due to exertion and other causes, and whose current history is within one month. Or patients who have had stable angina have not had pain for several months, but only in the last month or more angina again. Patients with this type of angina are relatively young and in relatively good physical condition, and thus exhibit more variability in symptoms. It seems to be less relevant in terms of the degree of physical effort, and sometimes it even occurs at rest. About 8-15% of patients with this type may evolve into acute myocardial infarction within the first month. After the appearance of the initial angina, most of them can be transformed into more stable angina, but the possibility of a slight loss of angina in a few patients cannot be excluded.
3==4==2==1==2 Stable angina pectoris
This is the most common type of angina in clinical practice. It means that the intensity, nature, frequency, location, and duration of the exertional angina attack and the triggering activity do not differ much within three, and the effect is produced within the same period of time by rest or nitroglycerin-containing chemotherapy.
3==4==2==1==3 Worsening angina pectoris
The original presentation was stable angina, but within the last three months, the duration and frequency of pain episodes, intensity, nature and part of the pain have changed compared to the previous ones, showing a worsening tendency of longer duration, excessive frequency, and increased pain level. This type of angina is noteworthy for its tendency to be markedly unstable and may progress to myocardial infarction or sudden death in 8-10% of patients, but it may also return to a stable type with a marked decrease in activity tolerance. In this type of attack, the electrocardiogram shows significant ST-segment depression, and T-wave inversion can still be seen even in remission, but serum enzymology is normal.
3==4==2===2 Spontaneous angina
This kind of angina attack is often without obvious trigger, that is to say, no obvious relationship with exertion or emotional excitement, and often exhibits a heavy degree of pain, longer duration, and insensitivity to nitroglycerin. It is probably due to the fact that its occurrence is not obviously related to myocardial oxygen consumption, but is mainly caused by a transient spasm of the coronary artery, resulting in insufficient blood supply to the coronary artery, so it is called spontaneous angina. It is also divided into the following three types according to its present.
3==4==2==2==2==1 Recumbent angina
It occurs at rest or during sleep, often in the middle of the night, and occasionally during naps. It mostly requires rising or standing to relieve angina pectoris, and may be associated with nightmares, low blood pressure at night, or conditions such as unrecognized left heart failure browning already present, resulting in insufficient myocardial blood perfusion in the distal unslight parts of already narrowed coronary arteries, or induced by conditions such as increased cardiac burden, increased workload, and increased oxygen demand due to excessive venous reflux in the recumbent position, which can further develop into myocardial infarction or sudden death.
3==4==2==2==2 Variable angina pectoris
This type is caused by coronary artery spasm and is similar to prone angina pectoris. However, during the attack, the electrocardiogram is elevated in the ST segment of the corresponding lead, and the attack is often accompanied by arrhythmias such as atrioventricular block and ventricular tachycardia. The episodes usually occur in the middle of the night at rest or in the early morning during normal activities. It is important to note that these patients will sooner or later develop myocardial infarction.
3==4==2==2==2==3 Post-infarction angina
Post-infarction angina is a condition that occurs within one month after the pain of an acute myocardial infarction has disappeared. It is also known as post-infarction angina, or early post-infarction angina, to distinguish it from combined angina after a stale myocardial infarction. The most common occurrence is around the 10th day of acute myocardial infarction, which occurs spontaneously at rest or during light activity. The pain occurs after coronary artery infarction when the myocardium is not completely necrotic and part of the non-necrotic myocardium is in a state of severe ischemia and hypoxia.
3==4==2===3 Mixed angina
It is characterized by angina pectoris occurring both when myocardial oxygen demand increases and when myocardial oxygen demand does not increase significantly and coronary blood supply decreases, that is, angina pectoris can be triggered by certain factors or can occur at rest without any trigger. This name was proposed only in 1985, and it was thought that the term mixed angina was recommended for diagnosis when angina occurs in patients with exertional angina who have some ability to work, even at a level of exertion that should be well tolerated at rest.
The above is the generally accepted typology of angina pectoris, but some scholars believe that primary angina pectoris, worsening angina pectoris, and all types of spontaneous angina pectoris are collectively referred to as unstable angina pectoris in a broad sense. Because it can develop into myocardial infarction or sudden death, it should be given higher attention in clinical work.
3==4==3 Myocardial infarction type coronary heart disease
This type of coronary heart disease is already a forward development and aggravation of coronary heart disease based on the first two types! It is the patient’s condition on the basis of coronary artery atherosclerosis, not in the first two types, only the patient’s heart muscle is sensitive to ischemia and hypoxia, but due to a small or large part of the myocardial blood supply disorder so that a sharp reduction or interruption of the myocardium occurred severe ischemia and hypoxia leading to myocardial necrosis. This is called myocardial infarction because of the infarction or obstruction of the blood supply to the myocardium. Clinical manifestations include severe and persistent pain behind the sternum, fever, shortness of breath, dyspnea, palpitations, etc. Laboratory tests have obvious indications, such as increased serum enzymes, persistent abnormal electrocardiograms, and significantly elevated white blood cells. Severe cases are accompanied by left heart failure, even arrhythmia, shock, and even sudden death. According to statistics, about 15-65% of patients have various pioneer-like symptoms, such as episodes of muscle weakness, especially in the extremities, or complaints of fatigue, loss of energy, indigestion, vomiting, or the sudden evolution of stable angina into worsening angina. The most prominent symptom is pain, especially chest pain, which lasts for a long time and cannot be relieved by taking cardioplegia, and the patient is anxious and restless. Accompanying symptoms are most common in the gastrointestinal tract, such as nausea, vomiting, abdominal distension, and sometimes the patient is seen with an acute abdomen. Fever mostly appears from the second onset, with a temperature of about 38℃. There are also many patients with atypical presentations, such as myocardial infarction starting with toothache and coronary artery disease in diabetic patients with 40% often without chest pain. These patients are easy to misdiagnose and delay treatment, so the mortality rate is high.
In these patients, strenuous physical work or activity, emotional stress, rapid rise in blood pressure and dehydration, bleeding, and severe arrhythmia become common triggering factors. It occurs mostly at night, which can be explained by the increased vagal tone at night, which makes the coronary artery spasm easily. The likelihood of myocardial infarction increases after a full meal, especially after eating large amounts of fatty foods, because platelets are more likely to adhere and aggregate.
There are various ways to classify myocardial infarction, and the common ones are as follows.
1 Classified by etiology, there are.
(1) Coronary atherosclerotic myocardial infarction.
(2) Non-coronary atherosclerotic myocardial infarction.
2 Classified by disease course and lesion area, there are
(1) Acute myocardial infarction
(2) old myocardial infarction
(3) Recurrent myocardial infarction
3 According to the location of the lesion, there are
(1) Atrial (in and right atrium) myocardial infarction
(2) Ventricular (left and right ventricular) myocardial infarction
4 According to the site of the lesion, there are
(1) Anterior myocardial infarction
(2) Lateral myocardial infarction
(3) Inferior wall myocardial infarction
(4) Posterior wall myocardial infarction
(5) interventricular myocardial infarction
(6) Papillary myocardial infarction
5 Classified by the extent of lesion involvement, there are.
(1) transmural myocardial infarction
(2) Non-mural myocardial infarction
(3) Subendocardial myocardial infarction
(4) Focal myocardial infarction.
3==4==4 Heart failure and arrhythmia type coronary heart disease
Patients with this type have acute heart failure or sudden arrhythmias as the first symptom, but often have a history of angina pectoris or myocardial infarction before the onset. Heart failure, especially left heart failure, is the most prominent. Premature ventricular beats are the most common arrhythmia, and atrioventricular block, sick sinus node syndrome, and atrial fibrillation may also be seen. The main reason is that part of the myocardial ring dies after a myocardial infarction and forms a scar in the corresponding part of the heart, so this part of the myocardium loses its contractile function, which affects the whole heart with weakened contraction, and the heart’s function of pumping blood is weakened, so that the symptoms of heart failure and arrhythmias such as palpitations, panic, shortness of breath, dyspnea, headache, dizziness, etc. come.
3==4==5 Sudden death coronary heart disease
Sudden death is a sudden, unanticipated death. At present, the understanding of sudden death is not the same, most domestic scholars believe that those who die within 1 hour after the onset of the disease are called sudden death, while the international World Health Organization stipulates that those who die within 6 hours after the onset of the disease are called sudden death. In the statistics of the causes of sudden death, it is found that more than 50% of them are caused by coronary heart disease, so it is considered necessary to divide them into sudden death coronary heart disease.
The causes of sudden death in coronary heart patients are many and complex. At present, the following are recognized as the main causes: (1) frequent premature ventricular oscillations, (2) persistent sinus bradycardia, (3) acute myocardial infarction with right bundle branch block, (4) patients with coronary artery disease who smoke more than once, and (5) patients with coronary artery disease who have undergone surgery such as bypass and strenuous physical labor.
Some patients have certain aura before the onset of the disease, such as chest tightness, shortness of breath, fatigue, nausea, vomiting. Most of them do not have any aura, but suddenly faint, lose consciousness, become unconscious, stop heartbeat, and stop the flow of blood throughout the body, and then die. Sudden death occurs at the age of 50 to 65 years old, especially at the age of 55 to 60 years old. The season of occurrence is mostly in winter, but it is rare in summer.