Pei, female, 76
Initial diagnosis: 2008-10-8
Chief complaint: paroxysmal precordial pain for more than 1 year, aggravated for 1 month.
Present history: 3 years ago, the pain in the precordial region appeared without any obvious cause, and was dull in nature, radiating to the submandibular area, left arm and left fingertip, accompanied by breath-holding and shortness of breath, each attack lasting about 3-5 min. In the past month, the pain has increased in frequency and intensity, and each attack can last for about 10 min. Last night and this morning, he had two episodes of pain in the precordial region, which were relieved by taking anti-cardiac pain. He was admitted to our department for systematic diagnosis and treatment. The symptoms: paroxysmal precordial pain radiating to the submandibular area, left arm and left fingertip, fatigue, no dizziness or panic, no profuse sweating, acceptable sleep, stool once a day, formed, urine regulated, light tongue, thin white coating, weak pulse.
Past history: hypertension for 26 years. single-chamber pacemaker implanted 9 years ago due to arrhythmia.
Auxiliary examination: resting ECG: sinus rhythm, normal cardiac axis. ST-segment depression in leads I, II, aVL, V2-V6 was 1-2 mm, and T-wave inversion in lead aVF (see figure). Cardiac ultrasound: (1) myocardial ischemia: the basal and mid segments of the posterior inferior left ventricular wall were hypokinetic and uncoordinated; (2) aortic valve insufficiency (mild); (3) mitral regurgitation (small amount). Carotid ultrasound showed carotid artery sclerosis and mild stenosis (bilateral). All three tests for heart attack were (-). BNP 561.9 pg/ml ↑ . TG 4.91 mmol/L ↑, TCH 9.0mmol/L ↑, HDL-C 1.07mmol/L ↓, LDL-C 5.92 mmol/L ↑, VLDL 2.01mmol/L ↑, Glu 7.96mmol/L ↑, FFA 0.841mmol/L ↑, UA 389.6 umol/L ↑.
Admission diagnosis: coronary atherosclerotic heart disease
Unstable angina pectoris
Heart not large
Sinus rhythm
Cardiac function class II
Treatment history.
①Next severe disease, continuous nasal catheter oxygenation.
②Western drug treatment: After admission, standardized western drug treatment was given according to the guidelines for secondary prevention of coronary heart disease, including dual antiplatelet and anticoagulation therapy, isosorbide nitrate intravenous pumping; oral beta-blocker bisoprolol, calcium channel blocker diltiazem (15mg, q6h); angiotensin-converting enzyme inhibitor captopril; lipid-lowering drug simvastatin.
(③) Chinese herbal medicine treatment: identify “qi deficiency and blood stasis”, and legislate to “benefit qi and activate blood”.
Peach kernel 12g
Safflower 12g
Angelica Sinensis 12g
Chuanxiong 12g
Red Peony 12g
Radix Rehmanniae 12g
Raw Astragalus 30g
Radix Codonopsis Pilosulae 20g
Atractylodes Macrocephala 20g
Second consultation: 2008-10-16
After 1 week of treatment, the patient still had recurrent episodes of pain in the precordial region, mostly during emotional excitement and at rest at night, with severe pain during the episodes, which was not relieved by nitroglycerin and required intravenous direct injection of isosorbide nitrate to relieve the pain, affecting sleep. There are 2-4 attacks per day. The tongue is red at the edges, with little fluid and less coating, no coating in the middle of the tongue and coating on both sides, white and greasy, with a weak pulse.
Western medicine treatment plan remains unchanged, herbal medicine legislation: activating blood circulation, resolving blood stasis, relieving spasm and pain
Prescription.
Peach kernel 12g
Safflower 12g
Angelica Sinensis 12g
Chuanxiong 12g
Bai Shao 12g
Radix Rehmanniae 12g
Citrus Aurantium 10g
Radix Bupleurum 15g
Whole Psidium Guajava 30g
Allium sativum 30g
Yuan Hu 12g
Yu Jin 12g
Whole Scorpion 10g
Centipede 2
Panax notoginseng powder 3g in solution
On 2008-10-26 at 7:10pm, there was an attack of chest tightness and palpitation, but no chest pain, and it lasted for 5min and relieved by itself. The ST segment depression in leads I, II, aVL and V2-V6 increased during the attack, which was considered to be related to coronary spasm, and diltiazem was increased to 30mg, q6h to strengthen the antispasmodic power. Since then, there was no more angina attack. He was discharged on October 31. He was advised to continue with the original prescription of tonics, together with the standardized treatment of western medicine.
Comments.
The patient was admitted to the hospital for unstable angina pectoris. The diagnosis was clear, namely, coronary atherosclerotic heart disease unstable angina pectoris, which could not be controlled by standardized western medicine treatment according to the guidelines for secondary prevention of coronary heart disease. The formula used peach kernel, safflower, angelica, Chuanxiong, raw earth, Chai Hu, Citrus aurantium, Yuan Hu, San Qi powder and Yu Jin to regulate qi and activate blood circulation and relieve pain, and used white peony, whole scorpion and centipede to relieve spasm and relieve pain, and used whole guadua and Allium sativum to dispel nodules and relieve pain. No adjustment was made to the Western medicine treatment. After adjustment of herbal treatment, the patient’s angina was quickly relieved and was seizure-free for 10 consecutive days. However, on 2008-10-26, there was one attack of resting chest pain, which lasted for 5 min and was relieved by itself. The western drug diltiazem (non-dihydropyridine calcium antagonist, relieves coronary spasm) was increased to 30 mg, q6h, and there was no more angina attack after that, suggesting that the combination of Chinese and western drugs is effective in controlling coronary spasm.