Coronary atherosclerotic heart disease is a heart disease caused by atherosclerotic lesions in the coronary vessels that narrow or block the lumen of the vessels, resulting in ischemia, hypoxia or necrosis of the myocardium, often referred to as “coronary heart disease”. However, the scope of coronary artery disease may be broader, including inflammation, embolism, etc., resulting in narrowing or occlusion of the lumen. The World Health Organization classifies coronary artery disease into five major categories: asymptomatic myocardial ischemia (occult coronary artery disease), angina pectoris, myocardial infarction, ischemic heart failure (ischemic heart disease), and sudden death. In the clinic, they are often divided into stable coronary heart disease and acute coronary syndrome.
1.Treatment of coronary heart disease
(1) Life habit change
Quit smoking and limit alcohol, low-fat and low-salt diet, appropriate physical exercise, weight control, etc.
(2) Drug treatment
antithrombotic (antiplatelet, anticoagulation), reduce myocardial oxygen consumption (beta-blockers), relieve angina pectoris (nitrates), stabilize plaque by lipid regulation (statin lipid regulators).
(3) Hemodynamic reconstruction therapy
This includes interventional therapy (endovascular balloon dilatation angioplasty and stenting) and surgical coronary artery bypass grafting. Drug therapy is the basis of all treatment. Interventional and surgical treatment is also followed by long-term standard drug therapy. For the same patient, medication is ideally controlled at one stage of the disease, while at another stage medication alone is often ineffective and needs to be combined with interventional or surgical procedures.
2.Drug therapy
The purpose is to relieve symptoms, reduce angina attacks and myocardial infarction; delay the development of coronary atherosclerotic lesions, and reduce coronary heart disease deaths. Standardized drug treatment can effectively reduce the mortality rate and the occurrence of re-ischemic events in patients with coronary heart disease and improve the clinical symptoms of patients. And for some patients with severe vascular lesions or even complete obstruction, revascularization therapy on top of drug therapy can further reduce the mortality of patients.
(1) Nitrate drugs
This class of drugs mainly includes: nitroglycerin, isosorbide nitrate (cardiac pain relief), isosorbide 5-mononitrate, long-acting nitroglycerin preparation (nitroglycerin ointment or rubber paste patch), etc. Nitrates are routinely used in patients with stable angina. Sublingual nitroglycerin or nitroglycerin aerosol can be used during angina attacks. For patients with acute myocardial infarction and unstable angina, the drugs should be given intravenously first, and then changed to oral or skin patches after the condition is stable and the symptoms improve, and the drugs can be stopped after the pain symptoms disappear completely. The continued use of nitrate drugs can occur resistance, effectiveness decreases, can be taken at intervals of 8 to 12 hours to reduce drug resistance.
(2) Anti-thrombotic drugs
Including antiplatelet and anticoagulant drugs. Anti-platelet drugs mainly include aspirin, clopidogrel (Bolivar), tirofiban, etc., which can inhibit platelet aggregation and avoid clot formation and blockage of blood vessels. Aspirin is the drug of choice, and the maintenance amount is 75-100 mg per day. All patients with coronary artery disease without contraindications should take it for a long time. The side effect of aspirin is irritation of the gastrointestinal tract, and it should be used with caution in patients with gastrointestinal ulcers. Daily oral clopidogrel should be maintained after coronary intervention, usually for 6 months to 1 year.
Anticoagulants include regular heparin, low molecular heparin, Juanda heparin sodium, and bivalirudin. They are usually used in the acute phase of unstable angina pectoris and myocardial infarction, as well as during interventional procedures.
(3) Fibrinolytic drugs
Thrombolytic drugs mainly include streptokinase, urokinase, tissue-type fibrinogen activator, etc., which can dissolve the formed thrombus at the coronary occlusion, open the blood vessel and restore blood flow, and are used in the acute myocardial infarction attack.
(4) β-blockers
β-blockers have angina pectoris effect and can prevent arrhythmia. In the absence of obvious contraindications, β-blockers are the first-line drugs for coronary heart disease. Commonly used drugs include metoprolol, atenolol, bisoprolol, carvedilol and armolol (Almare), which also have alpha-blocking effects, and the dose should be used to lower the heart rate to the target range. β-blockers are contraindicated and used with caution in conditions such as asthma, chronic bronchitis and peripheral vascular disease.
(5) Calcium channel blockers
They can be used in the treatment of stable angina and angina caused by coronary spasm. Commonly used drugs include: verapamil, nifedipine controlled release, amlodipine, diltiazem, etc. The use of short-acting calcium channel blockers, such as nifedipine generic tablets, is not advocated.
(6) Renin angiotensin system inhibitors
Including angiotensin-converting enzyme inhibitors (ACEI), angiotensin 2 receptor antagonists (ARB) and aldosterone antagonists. These drugs should be used especially in patients with acute myocardial infarction or recent myocardial infarction combined with cardiac insufficiency. Commonly used ACEI drugs are: enalapril, benazepril, ramipril, fosinopril, etc. ARBs include: valsartan, telmisartan, irbesartan, coxsartan, etc. If there are obvious side effects of dry cough, angiotensin 2 receptor antagonists can be used instead. Care should be taken to prevent low blood pressure during drug administration.
(7) Lipid-regulating therapy
Lipid-modifying therapy is applicable to all patients with coronary artery disease. Statins are given on the basis of lifestyle changes in coronary heart disease. statins mainly lower LDL cholesterol, and the therapeutic goal is to drop to 80 mg/dl. commonly used drugs include: lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, etc. Recent studies have shown that statins can reduce mortality and morbidity.
3.Percutaneous coronary intervention (PCI)
Percutaneous transluminal coronary angioplasty (PTCA) applies a specially designed catheter with a balloon, which is delivered to the coronary stenosis via a peripheral artery (femoral or radial artery). Filling the balloon dilates the narrowed lumen, improves blood flow, and places a stent in the dilated stenosis to prevent restenosis. It can also be combined with thrombus aspiration and rotational grinding. It is indicated for patients with stable angina pectoris, unstable angina pectoris and myocardial infarction that are poorly controlled by medications. Emergency intervention is preferred in the acute phase of myocardial infarction, and the timing is very important, the earlier the better.
4.Coronary artery bypass grafting (referred to as coronary artery bypass grafting, CABG)
Coronary artery bypass grafting relieves chest pain and local ischemia, improves patients’ quality of life, and can prolong their lives by restoring myocardial blood perfusion. It is indicated for patients with severe coronary artery disease, patients who cannot receive interventional therapy or who have relapsed after treatment, and patients with angina pectoris after myocardial infarction, or with complications such as ventricular wall aneurysm, mitral valve insufficiency, or septal perforation, who should undergo coronary artery bypass grafting while treating the complications. The choice of surgery should be decided by the cardiologist and cardiac surgeon together with the patient.
Warm tip: Please combine the specific medication with clinical, and be guided by the doctor’s face-to-face consultation.