In China, the incidence of coronary heart disease has shown a rapid increase in recent years, with nearly 50 million coronary heart disease patients. Meanwhile, the mortality rate has increased significantly, with the number of deaths exceeding 1 million/year, second only to malignant tumors. The current treatment methods mainly include drug therapy, interventional therapy, and surgical treatment. Among the surgical treatments, non-stop coronary artery bypass grafting is currently a respected surgical procedure at home and abroad. In order to provide scientific and reasonable medical guidance to patients with coronary artery disease, we interviewed professors of cardiac surgery and cardiology of the hospital on issues related to the diagnosis and treatment of coronary artery disease.
Moderator: First of all, we would like to thank the two directors for accepting our interview in their busy schedules. Coronary heart disease is a common disease, so it has become a term known to the general public, not just a disease name that medical professionals know. Because of its multiplicity, it is more harmful. Not only does it bring harm to the patient’s body, but it also puts a burden on the family and society. So, may I ask the director, how do I know if I have coronary heart disease?
Director: As the host said, coronary heart disease has now become a social disease because of its common and frequent occurrence. As for how to judge, we have to ask ourselves to pay attention to the following conditions, if they occur, may suffer from coronary heart disease.
1. When you are tired (such as physical activity, climbing, etc.) or nervous (such as watching thrilling movies, getting angry, etc.), you suddenly have pain in the back of the front wall of the chest right in the middle or in the left chest, and sometimes the pain is transmitted to the shoulder, arm or neck (called radiating pain). Some people can be accompanied by sweating, panic, shortness of breath, fatigue and difficulty in breathing.
2, in public places or meeting places, or when full, cold, going upstairs, climbing, than they used to, especially than others easily feel chest tightness, palpitations, breathlessness and not enough air.
3, night sleep when the pillow is low, feel suffocated, need high pillow lying; sleep or nightmare process suddenly awakened, feel palpitations, chest tightness, poor breathing, and even sweating, need to sit up before getting better.
4.Feeling heartbeat, shortness of breath, chest tightness or chest pain discomfort during sexual life, etc.
5.Long-term episodes of left shoulder pain that repeatedly does not heal with general treatment.
6.Recurring irregular pulse, too fast or too slow.
Moderator: May I ask the director how to determine if you have coronary heart disease if the above conditions occur?
Director: You can go to the hospital to measure blood pressure and do electrocardiogram. If the electrocardiogram has abnormal changes caused by cardiac ischemia, then the diagnosis can be basically confirmed, and you should further check blood lipids and blood sugar, and do cardiac ultrasound and coronary angiography if necessary. Among them, coronary angiography is a reliable method to confirm the diagnosis of coronary heart disease.
Moderator: Director, the main manifestation of coronary heart disease that you talked about earlier is chest pain, accompanied by shortness of breath. What kind of chest pain can be judged as pain caused by coronary heart disease?
Director: This is a good question, and it is indeed a more specialized question, because most chest pains are not caused by coronary heart disease. Then, the pain caused by coronary heart disease, also known as “angina pectoris”, which has the following characteristics.
1, the site of pain: mostly in the posterior sternum or chest of the precordial area (left anterior chest). A small number of them can be found anywhere between the upper abdomen and the pharynx. The individual manifests as heel (heel) pain.
2, the range of pain: the range of pain is often a piece, the patient can point out an approximate site but not the exact site, where the exact point of pain can be pointed out is often not angina.
3, the nature of the pain: angina in the elderly is often dull and burning pain is common, the pain is not as intense as young people. Sometimes angina in the elderly is not a painful sensation, but an uncomfortable feeling that is difficult to describe. Where the pain is needle-like or knife-like, it is often not true angina, but may come from pain in other organs.
4, pain radiation: angina is often not only chest pain, but also often radiates to the shoulder, upper limbs, neck or spine. The radiation to the left shoulder or left upper limb, from the inner forearm straight to the little finger and ring finger this range is more common.
5, the beginning of pain: angina is from the heart temporary ischemia and hypoxia slowly began, the pain is light at first, after a few minutes to reach the peak. If the pain is severe at the beginning and then gradually decreases, it is often not angina pectoris.
6, the duration of pain: the duration of typical angina is often about 3 to 5 minutes, rarely more than 10 to 15 minutes. Only a few variants of angina pectoris and myocardial infarction, pre-infarction angina pectoris longer. The pain is like a lightning-like fleeting is often not angina pectoris.
7, the interval of pain episodes: vary greatly from patient to patient, there are only 1 to 2 episodes in a few months or even a year, but there are also several episodes in a day or even an hour.
8, pain triggering factors: angina pectoris patients are mostly men over 40 years old. The traditional view is that exertion, emotional excitement, diet, cold, rainy weather as its triggers. However, the triggers of angina attack in the elderly are often unclear.
9, pain relief: those who have angina caused by physical activity, the pain disappears within a few seconds after stopping the activity, which is a very typical performance. For heavier episodes of angina, nitroglycerin can be used, and observation of the characteristics of pain relief can help diagnose angina.
10, the impact of position on pain: angina patients often do not want to lie down when they have an attack, but prefer to stand or sit. Because after lying flat, the amount of blood returning to the heart from the lower limbs increases, the burden on the heart increases, and the angina becomes more serious.
Familiarity with the above 10 conditions is very helpful in determining angina pectoris.
Moderator: May I ask the director, what other chest pains are easily confused with angina and how to distinguish them?
Director: In general, there are the following conditions that can help distinguish them. (1) The patient can point out or circle the range of chest pain with one finger, which is a point, a line, a small piece or symmetrical pain in the front and back of the chest; (2) The pain is needle-like or knife-like; (3) It lasts for a few seconds or up to several hours; (4) The chest tightness lasts for several hours or a whole day; (5) The pain does not appear during activity, but occurs at rest or at rest after activity; (6) The pain is relieved only after taking nitroglycerin for more than 10 minutes. These are not angina pectoris.
The diseases that are easily misdiagnosed as angina are mainly.
1, cardiac neurosis: the disease is more common in women, especially menopausal women. The manifestation is chest tightness or chest pain, pain is mostly a little, a line, a small or front chest and back symmetrical pain; lasts a few hours or a whole day, long breath to feel comfortable, mostly accompanied by heartburn, palpitations, sweating, poor sleep, and even feel that the room air is not enough, in the crowded occasions feel upset chest tightness, go outside or open the window to feel comfortable. The attacks are related to emotional tension, mental stress, and overexertion. Nitroglycerin is not effective or takes more than 10 minutes to relieve. This disease oral glutamate 50 mg / time, 3 times / day, can be effective.
2, esophageal hiatal hernia: the pain is located in the posterior sternum, easy to attack in sitting or lying position after a full meal, the pain is similar to angina pectoris, but less meals or after a meal in a standing position or walking for half an hour can eliminate the attack. Fiberoptic endoscopy or barium meal of the esophagus can help confirm the diagnosis. Surgical repair is required for treatment.
3, gastrointestinal diseases: such as reflux esophagitis, the patient’s pain is located behind the sternum, can be reflected to the jaw, shoulder, mostly at night or early morning attacks, often accompanied by heartburn, acid reflux, barium esophageal meal, fiberoptic endoscopy, esophageal pH measurement can help to confirm the diagnosis. It is effective with acid suppressants, H2 antagonists, proton pump inhibitors, and gastric motility drugs. In addition, esophageal spasm, cholecystitis, cholelithiasis, cardia spasm, and peptic ulcer need to be identified, and barium esophageal meal and hepatobiliary ultrasound can help in the diagnosis. It can be treated by gastroenterology medication and, if necessary, surgery by general surgery.
4, cervical spine osteophytes: cervical spondylosis can cause “cervical heart syndrome”, mostly seen in middle-aged and elderly people, some patients can have palpitations, chest tightness, episodes of precordial pain, arrhythmia, combined with dizziness. Patients often go to the cardiology department first, and are often misdiagnosed as angina pectoris. The main points of difference are: ①The episodes of precordial pain caused by cervical spondylosis last longer, usually lasting 1 to 2 hours. ②No significant effect of anti-anginal drugs. ③ Artificial compression of the cervical paravertebral pressure zone can induce angina-like attacks. This precordial pain often starts from the shoulder and interscapular region and then shifts to the precordial region, and the pain is aggravated by cervical arm activity and coughing, and the patient may also have other symptoms of cervical spondylosis, such as neck pain and numbness of the limbs. ④ Treatment according to cervical spondylosis can reduce the onset of pain in the precordial region. Cervical spine X-ray can help in diagnosis. Anti-osteoporotic drugs and physical therapy of rehabilitation department can be effective.
5.Non-ischemic heart disease: such as pericarditis and mitral valve prolapse can also cause chest pain. Doing cardiac ultrasound can differentiate. Surgical treatment by cardiac surgery is needed.
Moderator: Director, about how to identify coronary heart disease, you mentioned earlier that “coronary angiography” is a reliable method to diagnose coronary heart disease, please talk about this aspect.
Director: Yes, in 1958, Professor Sones of Cleveland Medical Center in Canada invented selective coronary angiography. This gave the medical community a clearer understanding of coronary artery disease and laid the foundation for interventional (stenting) and surgical (coronary artery bypass grafting) treatment of coronary artery disease. Coronary angiography is performed by puncturing the femoral artery at the heel of the patient’s thigh with an injection needle, inserting a very thin spring-like wire into the needle hole, pushing out the needle, and using a thin soft catheter to feed the artery along the spring-like wire to the heart, where a left ventriculogram is first performed to observe the systolic and diastolic functions of the heart, as well as the heart rate, the presence of atrial fibrillation, and the presence of ventricular wall tumors left by myocardial infarction. Then a left and right coronary angiogram is done so that all coronary arteries can be clearly seen for stenosis, as well as the exact location and degree of stenosis. Also, it is possible to see if there are any congenital malformations of the coronary arteries, such as coronary artery fistula, anomalous origin of the left coronary artery from the pulmonary artery (normal origin from the aorta), single coronary artery, coronary artery myocardial bridge compression, etc. From there, the treatment plan is decided: is it medication? Interventional treatment? or surgical treatment. The number of stents to be placed for interventional treatment and the number of bridges to be built for surgical treatment are also known in advance. Interventional treatment can be done at the same time as coronary angiography, but the new guidelines for the treatment of coronary artery disease are very strict about interventional treatment. At present, there is a phenomenon of indiscriminate stenting in China, which is irresponsible to patients.
Moderator: The current treatment methods for coronary artery disease include drug therapy, interventional therapy and surgical therapy. Please ask Director Xiao to talk about the situation of medical drug treatment.
Director: The treatment of coronary heart disease should first clarify the high-risk factors for the occurrence of coronary heart disease, which is the main cause of coronary heart disease. It is now recognized that risk factors for coronary heart disease, in addition to gender, age, poor lifestyle habits and family history, hypertension, diabetes, hyperlipidemia and smoking, are considered to be the four most important risk factors for coronary heart disease. Therefore, the first step of treatment is to quit smoking.
Second, control blood pressure.
1, the determination of hypertension: China’s hypertension diagnostic criteria are developed with reference to the World Health Organization and the International Society of Hypertension standards. Specifically, systolic blood pressure (high pressure) greater than or equal to 140 mmHg and/or diastolic blood pressure (low pressure) greater than or equal to 90 mmHg, even if hypertension. At the same time, the patient has a history of hypertension in the past and is currently taking hypertension medication, although both blood pressure is lower than 140/90mmHg, should also be diagnosed as hypertension.
2, what is the ideal blood pressure for patients with coronary heart disease: in principle, blood pressure should be controlled below 140/90 mmHg, and for patients with coronary heart disease, stroke, diabetes or chronic kidney disease combined with hypertension, the target value of blood pressure control is 130/80 mmHg. The goal of blood pressure reduction for simple systolic hypertension in the elderly is a high pressure of 140~150 mmHg and a low pressure of less than 90 mmHg, but not less than 65~70 mmHg.
3, to understand the antihypertensive drugs into which categories? How should patients with coronary artery disease take antihypertensive drugs? These are used under the guidance of doctors. Antihypertensive drugs mainly include diuretics, beta-blockers, calcium antagonists, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonists (ARB) and several others, but there is no certain rule on which drug should be used in what kind of situation. It is important to note that most antihypertensive drugs have a clinical onset of action of 4-6 weeks, and physicians need sufficient time to gradually adjust the medication. Secondly, several antihypertensive drugs have their own advantages and disadvantages, different mechanisms of action, indications and side effects, so they usually need to be used in combination to avoid shortcomings. Again, antihypertensive drugs need to be taken for a long time. It can be said that all the current antihypertensive treatment can not cure hypertension, so long-term treatment is necessary, even if the blood pressure has been reduced to normal values, you can not stop the drug. Finally, it should be noted that some patients without symptoms in the beginning of antihypertensive drugs, but will appear dizziness, weakness and other uncomfortable symptoms, this is a normal phenomenon, as long as adhere to a period of time will naturally disappear, can not therefore refuse the drug, delayed treatment.
Third, control blood lipids. Because high blood lipid is the main cause of coronary heart disease.
1, clear what is high blood lipid? Cholesterol, triglycerides and lipids (including phospholipids, glycolipids, steroids) in human blood, these are collectively called lipids. The diagnosis of hyperlipidemia mainly relies on laboratory tests, the most important of which is the measurement of blood cholesterol and triglycerides. If blood cholesterol exceeds 5.72 mmol/L (220 mg%) and/or triglycerides exceed 1.76 mmol/L (160 mg%), the diagnosis is generally established.
2, diet control: the dietary principles for patients with hyperlipidemia should be: low calories, low cholesterol, low fat, low sugar and high fiber. Several foods have been found in research to be not only nutritious but also cholesterol-lowering. The main ones are: soy products, shiitake mushrooms, black fungus, onion, garlic, sea fish, skim milk, yogurt, tea, and other coarse grains, dried beans, kelp, fresh vegetables, fruits, etc.
3.Medication: use statin drugs, sulforaphane, etc. under the guidance of doctors.
Fourth, treatment of diabetes. Most of the patients with coronary heart disease combined with diabetes, diabetes is also an important factor that causes and aggravates coronary heart disease.
1, only early detection of diabetes can be effectively treated. Therefore, those who have the characteristics of high-risk groups should be more alert to diabetes. Positive urine sugar can provide clues for the diagnosis of diabetes, and the diagnosis can only be based on blood sugar, so those who suspect diabetes must go to the hospital to check blood sugar as soon as possible. When fasting blood sugar ≥7.0mmol/l (126mg/dl) or two hours after meal blood sugar ≥11.1
mmol/l (200mg/dl), then diabetes can be diagnosed.
2.Diet control: Basically, you can refer to the dietary principles for patients with hyperlipidemia.
3.Drug control: Blood sugar control is a scientific, long and complicated process. Doctors should adjust the amount of medication at any time according to the patient’s blood sugar value, and should ask the professional physician of endocrinology to guide the medication.
Moderator: Thank you for your long and detailed explanation. Please tell us more about what patients are suitable for interventional treatment (stenting) or coronary artery bypass grafting and how their results compare.
Director: In 1977, Gruentzing performed the first international percutaneous transluminal coronary angioplasty (PTCA), which was successful.
Sigwart was the first to apply intracoronary stenting to clinical practice in 1987. Since then, the development of interventional techniques has put an end to the history that only cardiac surgeons could perform revascularization, posing a great challenge to coronary artery bypass grafting. After 20 years of development and refinement, and through comparative studies of a large number of previous procedures, physicians in cardiac medicine and surgery have basically reached a consensus: for patients with single-branch lesions, the long-term survival rates of interventional therapy and coronary artery bypass grafting are similar to the incidence of myocardial infarction, but patients who receive interventional therapy (stent placement) require significantly more anti-anginal medication than coronary artery bypass grafting, mainly due to the fact that after interventional therapy This is mainly due to the restenosis of the coronary artery after intervention.
In patients with multiple lesions, there was no significant difference in the overall mortality, cardiac death, or myocardial infarction rates between intervention and coronary artery bypass grafting. However, the incidence of restenosis was significantly higher after intervention than after coronary artery bypass grafting, and the functional improvement was not as good as with coronary artery bypass grafting. According to the analysis, coronary artery bypass grafting is more effective in patients with diabetes mellitus, multiple diffuse lesions, left ventricular hypoperfusion, multiple lesions distal to the left main stem of the coronary artery and with anterior descending branch opening lesions, and in patients who cannot achieve complete revascularization by interventional therapy. Only interventional treatment is less invasive and less painful, while coronary artery bypass grafting is more invasive.
Moderator: Director, please tell us about coronary artery bypass grafting.
Director: Yes, in 1964, Dr. Garrett in the United States found a patient with a left coronary artery lesion located at the bifurcation of the vessel and could not perform the scheduled endovascular dissection, so he cut a section of the saphenous vein to make an anastomosis between the ascending aorta and the left coronary artery. Dr. Garrett became the first person in the world to perform a successful coronary artery bypass graft. In October 1974, Prof. Guo Jianqiang successfully performed the first coronary artery bypass graft in China using the saphenous vein as the bridge vessel, after which coronary artery bypass grafting slowly began in China until 1992, when the total number of surgical cases in China was less than 500, mainly due to the limitation of coronary angiography. In recent years, with the increase of international exchange, some foreign-trained young physicians have returned to China to work, so that coronary artery bypass grafting in China has made rapid development, and the surgical techniques and treatment results have kept pace with international.
Moderator: Director Lv, you have carried out non-stop coronary artery bypass grafting in Tai Medical Hospital, and mentioned that coronary artery bypass grafting under the beating heart is currently a respected surgical method at home and abroad. Could you please tell us more about this aspect?
Director: Yes. As mentioned earlier, Professor Gu Chengxiong is the leader of non-stop coronary artery bypass surgery in China, and is known as the “first person in Asia” in coronary artery bypass surgery in the medical field. In view of this situation, Taishan Medical College has appointed Professor Gu Chengxiong as our “Visiting Professor”, and Professor Gu comes to our hospital to perform and instruct surgeries at any time upon patients’ request. It is under the guidance of Professor Gu that our cardiac surgery department has successfully carried out non-stop coronary artery bypass grafting.
Moderator: What should be done before the non-stop coronary artery bypass surgery?
Director: Before surgery, coronary artery, left ventricle and internal mammary artery imaging must be done to clarify the site and degree of coronary artery stenosis, and accordingly decide the number of bypasses and the exact location. Echocardiogram, electrocardiogram, blood biochemistry; lung, liver, kidney function and routine urine and stool tests are also required to understand the functional status of all organs of the body. Infection should be strictly controlled before surgery. Patients should practice abdominal breathing and stop using drugs such as aspirin. Control hypertension, control blood sugar, treatment and prevention of inflammation, lower serum cholesterol, quit smoking before surgery, and increase physical activity appropriately. Be optimistic and cheerful, feel comfortable, avoid excessive mental tension, because too much mental tension can easily cause coronary artery spasm and produce myocardial infarction and increase the risk of surgery.
Moderator: It must be very difficult to perform coronary artery bypass in a beating heart, please briefly introduce the operation.
Director: Indeed, performing coronary artery bypass surgery while the heart is beating is a very complex, technically demanding and difficult surgery with high patient injury. We use Professor Gu Chengxiong’s surgical approach: the left internal mammary artery (also called the internal thoracic artery) is used to bypass the anterior descending branch, and a saphenous vein is used to bypass the diagonal branch, obtuse marginal branch, and posterior descending branch in sequence. We call this “sequential bypass”. The sequential bypass of the left internal mammary artery and the saphenous vein is performed by freeing the patient’s own left internal mammary artery and then anastomosing it with the anterior descending branch of the left coronary artery, the main vessel supplying blood to the heart, and then using a saphenous vein to anastomose the diagonal branch, the obtuse marginal branch, and the posterior descending branch in turn. Blood is supplied to the ischemic heart muscle. This method is very difficult to perform, and the operator must be extremely delicate and precise in his operation. Therefore, the surgeon is required to have extremely rich practical experience in coronary surgery.
Based on the analysis of a large number of coronary artery bypass surgery cases, it is confirmed that the internal mammary artery is the best known bypass material in the human body, but there is only one left and one right. In general bypass surgery, only the left internal mammary artery is used as bypass material, and the rest of the material is commonly used for the saphenous vein to prevent the sternum from not healing or necrosis after bilateral internal mammary artery removal. The radial artery and the gastroretinal artery are secondary vessels, which are prone to spasm (thinning or occlusion) after bypass, and we no longer use them at present.
The reason why the internal mammary artery is the best known bypass material in the body is because of its high long-term patency rate. Expert studies have shown that after 10 years of bypass with an internal mammary artery bridge, the patency rate is over 90%. This is due to the fact that the caliber of internal mammary artery as bypass material is more compatible with the caliber of coronary artery, which is less likely to spasm, and the internal mammary artery is a living vessel with a tip, which has a high flow rate and the diameter of the tube can increase with the increase of flow load. Moreover, the length of bilateral internal mammary arteries is sufficient to cover all important coronary vessels. Patients who have undergone heart bypass surgery using this method at Anzhen Hospital and Tai Medical College have recovered well and were discharged from the hospital.
Moderator: What medications should I continue to take after coronary artery bypass surgery? How to follow up?
Director: First of all, whether it is interventional surgery or bypass surgery is different from other surgeries, even if the surgery is successful and the patient is discharged safely, there is still the problem of restenosis of coronary arteries and bridge vessels, so in order to protect our heart, the following drugs must be taken for a long time: antiplatelet agents (aspirin, etc.) nitrates (anti-cardiac pain, etc.) lipid-lowering drugs (sulforaphane, etc.) beta-blockers (betalactam, etc.). Betalactone, etc.). Patients with hypertension and diabetes also need to take antihypertensive and hypoglycemic drugs on time. Do not reduce the dosage or stop the medication without authorization.
Next, pay attention to the postoperative review schedule and related precautions.
Review cardiac ultrasound, chest X-ray, electrocardiogram, and blood biochemistry 3 months after surgery. After the surgery, it will be rechecked once a year, so that the doctor can grasp the condition and use the medication reasonably.
Patients with coronary artery bypass grafting often have myocardial ischemia on the ECG after the surgery, which does not indicate obstruction or occlusion of the bridge vessel. If the preoperative angina and other symptoms disappear, it means that the bypass vessel is still open and effective. However, the progression of atherosclerotic changes in the body that cause coronary artery disease may still form new coronary artery obstruction, or the bridge vessel may become narrowed or occluded again for various reasons, thus affecting the effect of bypass surgery. Therefore, stopping or relieving the development of atherosclerosis and preventing the stenosis or occlusion of the bridge vessels become the purpose of long-term continuous treatment for bypass patients after surgery, which requires long-term testing of blood lipids, blood sugar and blood pressure.
Moderator: Once again, we would like to express our gratitude to the two experts for accepting our interview! We sincerely hope that this interview can bring help to the majority of friends suffering from coronary heart disease. Because of time, this interview is over. If you still need to consult, please call the experts, or contact our newspaper.