Atypical forms of infarction. Features of the course and therapy of the cerebral form of myocardial infarction

The asthmatic variant of myocardial infarction (5-10%), proceeding as cardiac asthma or pulmonary edema, is more common in elderly or senile people against the background of pronounced myocardial changes due to hypertension, cardiosclerosis, often with extensive transmural myocardial infarctions.

The asthmatic form of myocardial infarction proceeds very unfavorably and often ends in death.

Differential diagnostic signs of myocardial infarction

… the problem of heart attack has not been fully resolved, mortality from it continues to increase.

Myocardial infarction, allergic and infectious-toxic shock. Severe retrosternal pain, shortness of breath, drop in blood pressure are symptoms that occur with anaphylactic and infectious-toxic shock. anaphylactic shock can occur with any drug intolerance. The onset of the disease is acute, clearly confined to the causative factor (injection of an antibiotic, vaccination to prevent an infectious disease, administration of tetanus toxoid, etc.). Sometimes the disease begins 5-8 days after the iatrogenic intervention, develops according to the Arthus phenomenon, in which the heart acts as a shock organ. Infectious-toxic shock with myocardial damage can occur with any severe infectious disease (pneumonia, tonsillitis, etc.).

Clinically, the disease is very similar to myocardial infarction, differing from it in the etiological factors listed above. Differentiation is all the more difficult because in case of allergic and infectious-allergic shock, non-coronary myocardial necrosis can occur with gross ECG changes, leukocytosis, increased ESR, hyperenzymemia of AsAT, LDH, HBD, CPK, and even CF CF. Unlike a typical myocardial infarction, such patients do not have a deep Q wave on the ECG, and even more so the QS complex, discordance of changes in the final part.

Myocardial infarction and pericarditis (myopericarditis). The etiological factors of pericarditis are rheumatism, tuberculosis, viral infection (usually Coxsackie or Echo virus), diffuse connective tissue diseases. Pericarditis often occurs in patients with terminal chronic renal failure. In acute pericarditis, the subepicardial layers of the myocardium are often involved in the process.

In a typical variant, with dry pericarditis, there are dull, pressing, less often acute pains in the precordial region without irradiation to the back, under the shoulder blade, to the left arm, characteristic of myocardial infarction. Shui friction of the pericardium is recorded on the same days as an increase in body temperature, leukocytosis, an increase in ESR. It is persistent, auscultated for several days, weeks. In myocardial infarction, the pericardial friction noise is short-term, in hours, precedes fever, an increase in ESR. If heart failure appears in patients with pericarditis, then it is right ventricular or biventricular. Myocardial infarction is characterized by left ventricular failure. The differential diagnostic value of enzymological tests is low. Due to damage to the subepicardial layers of the myocardium in patients with pericarditis, hyperenzymemia of AST, LDH, LDH1, HBD, CPK, and even MB isoenzyme of CPK can be recorded.

The ECG data helps in the diagnosis. In pericarditis, there are symptoms of subepicardial injury in the form of ST elevation in all 12 conventional leads (no discordance characteristic of myocardial infarction). The Q wave in pericarditis, unlike myocardial infarction, is not detected. The T wave with pericarditis can be negative, it becomes positive after 2-3 weeks from the onset of the disease. With the appearance of pericardial exudate, the x-ray picture becomes very characteristic.

Myocardial infarction and left-sided pneumonia. With pneumonia, pain may appear in the left half of the chest, sometimes intense. However, unlike precordial pain in myocardial infarction, they are clearly associated with breathing and coughing and do not have irradiation typical of myocardial infarction. A productive cough is characteristic of pneumonia. The onset of the disease (chills, fever, fighting in the side, pleural friction rub) is not at all typical for myocardial infarction. Physical and x-ray changes in the lungs help diagnose pneumonia. ECG with pneumonia may change (low T wave, tachycardia), but there are never changes resembling those of myocardial infarction. As with myocardial infarction, pneumonia can detect leukocytosis, an increase in ESR, hyperenzymemia of AST, LDH, but only with myocardial damage does the activity of HBD, LDH1, and CPK MV increase.

Myocardial infarction and spontaneous pneumothorax. With pneumothorax, there is severe pain in the side, shortness of breath, tachycardia. Unlike myocardial infarction, spontaneous pneumothorax is accompanied by a tympanic percussion tone on the side of the lesion, weakening of breathing, radiographic changes (gas bubble, lung collapse, displacement of the heart and mediastinum to the healthy side). ECG parameters with spontaneous pneumothorax are either normal, or a transient decrease in the T wave is detected. Leukocytosis, an increase in ESR with pneumothorax does not happen. Serum enzyme activity is normal.

Myocardial infarction and chest contusion. With both diseases, severe chest pains occur, shock is possible. Concussion and contusion of the chest lead to myocardial damage, which is accompanied by elevation or depression of the ST interval, T-wave negativity, and in severe cases even the appearance of an abnormal Q wave. The anamnesis plays a decisive role in making the correct diagnosis. The clinical assessment of chest contusion with ECG changes should be serious enough, since these changes are based on non-coronary myocardial necrosis.

Myocardial infarction and osteochondrosis of the thoracic spine with root compression. With osteochondrosis with radicular syndrome, pain in the chest on the left can be very strong, unbearable. But, unlike pain from myocardial infarction, they disappear when the patient "freezes" in a forced position, and sharply intensifies when turning the torso and breathing. Nitroglycerin, nitrates in osteochondrosis are completely ineffective. significant effect of analgesics. With chest "sciatica", a clear local pain is determined in the paravertebral points, less often along the intercostal space. The number of leukocytes, ESR, enzymological parameters, ECG within the normal range.

Myocardial infarction and herpes zoster. The clinic of herpes zoster is very similar to that described above (see the description of the symptoms of radicular syndrome in osteochondrosis of the spine in the thoracic region). In some patients, fever may be recorded in combination with moderate leukocytosis, an increase in ESR. ECG, enzyme tests, as a rule, often help to exclude the diagnosis of myocardial infarction. The diagnosis of "shingles" becomes reliable from 2-4 days of illness, when a characteristic bubble (vesicular) rash appears along the intercostal spaces.

LEADING SYMPTOM - CARDIAC ASTHMA

The asthmatic variant of myocardial infarction in its pure form is rare, more often suffocation is combined with pain in the precordial region, arrhythmia, and symptoms of shock. Acute left ventricular failure complicates the course of many heart diseases, including cardiomyopathies, valvular and congenital heart diseases, myocarditis, etc.

In order to correctly diagnose myocardial infarction (asthmatic variant), one must be able to take into account many signs of this disease in various clinical situations. (1) when a syndrome of acute left ventricular failure occurs in hypertensive crisis; (2) when it occurs in persons who have had a previous myocardial infarction, suffering from angina pectoris; (3) when suffocation occurs in patients with any rhythm disturbance, especially with unreasonable tachysystole; (4) in a first or recurrent attack of cardiac asthma in a middle-aged, elderly, or older person; (5) when symptoms of “mixed” asthma appear in an elderly patient who has suffered from bronchopulmonary disease with episodes of bronchial obstruction for a number of years.

THE LEADING SYMPTOM IS ACUTE ABDOMINAL PAIN, FALLING IN ARTERIAL PRESSURE

Myocardial infarction and acute cholecystic pancreatitis. In acute cholecystopancreatitis, as in the gastralgic variant of myocardial infarction, there are severe pains in the epigastric region, accompanied by weakness, sweating, and hypotension. However, pain in acute cholecystopancreatitis is localized not only in the epigastrium, but also in the right hypochondrium, radiating up and to the right, to the back, sometimes it can be girdle. Their combination with nausea, vomiting is natural, and an admixture of bile is determined in the vomit. Pain is determined by palpation at the point of the gallbladder, projections of the pancreas, positive symptoms of Kera, Ortner, Mussy, which is not typical for myocardial infarction. Bloating, local tension in the right upper quadrant is not typical for myocardial infarction.

Leukocytosis, increased erythrocyte sedimentation rate, hyperenzymemia of AST, LDH can appear in both diseases. With cholecystopancreatitis, there is an increase in the activity of alpha-amylase in blood serum and urine, LDH 3-5. In myocardial infarction, one should be guided by high rates of enzymatic activity of CPK, CF CPK, HBD.

ECG in acute cholecystopancreatitis may change. This is a decrease in the ST interval in a number of leads, a weakly negative or biphasic T.N.K. Permyakov described large-focal myocardial damage in patients with acute cholecystopcreatitis, more often in cases of severe pancreatic necrosis, using morphological material. During their lifetime, these patients complained of intense abdominal pain, dyspeptic disorders, and collapse. ECG changes were infarct-like. The activity of serumal enzymes, including CPK, MB CPK, sharply increased. These data were confirmed by V.P. Polyakov, B.L. Movshovich, G.G. Saveliev in the observation of patients with acute pancreatitis, cholecystitis in combination with diabetes mellitus. These data were defined as non-coronary, metabolic, due to the direct toxic effect of proteolytic enzymes on the myocardium, imbalance of the kinin-kallikrein system, and electrolyte disturbances. Large-focal metabolic damage to the myocardium significantly worsens the prognosis of pancreatitis, and is often the leading factor in death.

Myocardial infarction and perforated stomach ulcer. Acute pain in the epigastrium is characteristic of both diseases. However, with a perforated stomach ulcer, pain in the epigastrium is unbearable, “dagger-like”. Their maximum severity is at the moment of perforation, then the pains spontaneously decrease in intensity, their epicenter shifts somewhat to the right and down. In the gastralgic variant of myocardial infarction, pain in the epigastrium can be intense, but they are not characterized by such an acute, instant onset followed by a decline, as with a perforated stomach ulcer.

With a perforated stomach ulcer, the symptoms change after 2-4 hours from the moment of perforation. Patients with a perforated gastroduodenal ulcer develop symptoms of intoxication; the tongue becomes dry, the facial expression changes, its features become sharper. The abdomen becomes retracted, tense, the symptoms of irritation are positive, the “disappearance” of hepatic dullness is determined by percussion, air under the right dome of the diaphragm is detected radiologically. Body temperature can be subfebrile in both diseases, as well as moderate leukocytosis during the first day. An increase in the activity of serum enzymes (LDH, CPK, MB CPK) is characteristic of myocardial infarction. ECG with a perforated stomach ulcer during the first day, as a rule, does not change. The next day, changes in the final part are possible due to electrolyte disturbances.

Myocardial infarction and gastric cancer. With cancer of the cardia, intense pressing pains in the epigastrium and under the xiphoid process often occur, combined with transient hypotension. To exclude the gastralgic variant of myocardial infarction in such cases, an ECG study is performed. The ECG reveals changes in the ST interval (usually depression) and the T wave (isoelectric or slightly negative) in III, avF leads, which serves as a reason for diagnosing small-focal posterior myocardial infarction.

Unlike myocardial infarction in cardia cancer, epigastric pain naturally recurs daily, they are associated with food intake. ESR increases in both diseases, however, the dynamics of the activity of CPK, MB CPK, LDH, and HBD enzymes is characteristic only for myocardial infarction. With cancer of the cardia, the ECG is “frozen”, it fails to determine the dynamics characteristic of myocardial infarction. Cancer diagnosis is being confirmed. first of all, FGDS, X-ray examination of the stomach in various positions of the body of the subject, including in the position of anti-orthostasis.

Myocardial infarction and food poisoning. With both diseases, pain in the epigastrium appears, blood pressure drops. However, epigastric pain with nausea. vomiting, hypothermia is more typical for food poisoning. Diarrhea does not always occur with foodborne illness, but it never occurs with myocardial infarction. The ECG during food poisoning either does not change, or during the study, “electrolyte disturbances” are determined in the form of a trough-shaped downward shift in the ST interval, a weakly negative or isoelectric T wave. Laboratory studies with food poisoning show moderate leukocytosis, erythrocytosis (blood thickening), a slight increase in ALT activity , AST, LDH without significant changes in the activity of CK, CF CK, HBD, characteristic of myocardial infarction.

Myocardial infarction and acute mesenteric circulation disorder. Epigastric pain, a drop in blood pressure occur in both diseases. Difficulties in differential diagnosis are exacerbated by the fact that thrombosis of mesenteric vessels, like myocardial infarction, usually affects elderly people with various clinical manifestations of coronary artery disease, with arterial hypertension. In case of circulatory disorders in the system of mesenteric vessels, pain is localized not only in the epigastrium, but also throughout the abdomen. The abdomen is moderately inflated, auscultatory sounds of intestinal peristalsis are not detected, symptoms of peritoneal irritation may be detected. To clarify the diagnosis, an abdominal x-ray should be taken to determine the presence or absence of intestinal motility and the accumulation of gas in the intestinal loops. Violation of the mesenteric circulation is not accompanied by changes in the ECG and enzyme parameters characteristic of myocardial infarction. If it is difficult to diagnose thrombosis of the mesenteric vessels, pathognomonic changes can be detected during laparoscopy and angiography.

Myocardial infarction and dissecting abdominal aortic aneurysm. In the abdominal form of dissecting aortic aneurysm, in contrast to the gastralgic variant of myocardial infarction, the following symptoms are characteristic (Zenin V.I.): the onset of the disease with chest pain; undulating nature of the pain syndrome with irradiation to the lower back along the spine; the appearance of a tumor-like formation of an elastic consistency, pulsating synchronously with the heart, the appearance of a systolic murmur over this tumor-like formation; increase in anemia.

When interpreting the symptom "acute pain in the epigastrium" in combination with hypotension in the differential diagnosis with myocardial infarction, one must also keep in mind more rare diseases. acute adrenal insufficiency; rupture of the liver, spleen or hollow organ in trauma; syphilitic dryness of the spinal cord with tabetic gastric crises (anisocoria, ptosis, reflex immobility of the eyeballs, optic nerve atrophy, ataxia, absence of knee reflexes); abdominal crises with hyperglycemia, ketoacidosis in patients with diabetes mellitus.

LEADING SYMPTOM - "INFARCTION-LIKE" ELECTROCARDIOGRAM

Non-coronary myocardial necrosis can occur with thyrotoxicosis, leukemia and anemia, systemic vasculitis, hypo- and hyperglycemic conditions. In the pathogenesis of non-coronary myocardial necrosis, there is an imbalance between myocardial oxygen demand and its delivery through the coronary artery system. With thyrotoxicosis, the metabolic demand sharply increases without adequate provision. With anemia, leukemia, diabetes mellitus (coma), gross metabolic disorders occur in the cardiomyocyte. Systemic vasculitis leads to a gross violation of microcirculation in the myocardium. In acute poisoning, direct toxic damage to myocardial cells occurs. The morphological essence of myocardial damage is similar in all cases: these are multiple small-focal necrosis of cardiomyocytes.

Clinically, against the background of the symptoms of the underlying disease, there are pains in the heart, sometimes severe, shortness of breath. Data from laboratory studies are uninformative in the differentiation of non-coronary necrosis with myocardial infarction of atherosclerotic origin. Hyperenzymemia of LDH, LDH1, HBD, CPK, CF CF are caused by myocardial necrosis as such, regardless of their etiology. ECG with non-coronary myocardial necrosis reveals changes in the final part - depression or, less commonly, ST interval elevation, negative T waves, with subsequent dynamics corresponding to non-transmural myocardial infarction. An accurate diagnosis is established on the basis of all the symptoms of the disease. Only this approach makes it possible to methodically correctly assess the actual cardiac pathology.

Myocardial infarction and heart tumors (primary and metastatic). With tumors of the heart, persistent intense pain in the precordial region, resistant to nitrates, heart failure, and arrhythmias may appear. On the ECG - a pathological Q wave, ST interval elevation, a negative T wave. Unlike myocardial infarction, with a heart tumor there is no typical evolution of the ECG, it is not dynamic. Heart failure, arrhythmias refractory to treatment. The diagnosis is specified with a thorough analysis of clinical, radiological and echocardiographic data.

Myocardial infarction and post-tachycardial syndrome. Post-tachycardia syndrome is an ECG phenomenon that manifests itself in transient myocardial ischemia (ST interval depression, negative T wave) after tachyarrhythmia relief. This symptom complex must be evaluated very carefully. Firstly, tachyarrhythmia can be the beginning of myocardial infarction, and ECG after its relief often only reveals infarct changes. Secondly, an attack of tachyarrhythmia of such a degree disrupts hemodynamics and coronary blood flow that it can lead to the development of myocardial necrosis, especially in initially defective coronary circulation in patients with stenosing coronary atherosclerosis. Therefore, the diagnosis of posttachycardial syndrome is reliable after careful observation of the patient, taking into account the dynamics of clinical, echocardiographic, laboratory data.

Myocardial infarction and premature ventricular repolarization syndrome. The syndrome of premature ventricular repolarization is expressed in the elevation of the ST interval in the Wilson leads, starting from the J point (junction) located on the descending knee of the R wave. This syndrome is recorded in healthy people, athletes, patients with neurocirculatory dystonia. To make a correct diagnosis, you need to know about the existence of an ECG phenomenon - premature ventricular repolarization syndrome. With this syndrome, there is no clinic of myocardial infarction, there is no ECG dynamics characteristic of it.

Cardiologist

Higher education:

Cardiologist

Saratov State Medical University. IN AND. Razumovsky (SSMU, media)

Level of education - Specialist

Additional education:

"Emergency Cardiology"

1990 - Ryazan Medical Institute named after Academician I.P. Pavlova

The main symptom of myocardial infarction is pain. The “cores” are well aware of this and are guided by this particular symptom. But even doctors are sometimes lost when a heart attack manifests itself in syndromes that are not characteristic of it. What you need to know about an atypical heart attack in order to recognize it in time and not “carry it” on your feet?

What is an atypical form?

The main saving signal for a person with any illness is pain. According to its presence, two types of heart attacks are distinguished. A typical form of myocardial infarction makes itself felt with severe pain behind the sternum. Atypical forms of myocardial infarction manifest themselves as pains of a different localization or their complete absence. In this regard, they are divided into painful and painless.

Depending on the place of occurrence of pain and the addition of other non-characteristic symptoms, several atypical forms of a heart attack are distinguished. Most often they are diagnosed in older people, due to their diseases - atherosclerosis, cardiac ischemia, gastrointestinal and neurological pathologies. The abdominal form of a heart attack is typical for relatively young patients. Concomitant diseases can worsen during a heart attack and also affect its clinical picture. Cases when the probability of developing an atypical form of a heart attack is high:

severe form of heart failure with congestion;
cardiosclerosis;
hypertension with high numbers;
diabetes mellitus (due to decreased sensitivity to pain);
not the first myocardial infarction.

Atypical forms are type 2 myocardial infarction. It develops due to an imbalance between the need of the heart muscle for oxygen and its actual supply with blood. The reason is coronary spasm, embolism (blockage by a thrombus) of the coronary arteries, anemia, jumps in blood pressure.

Forms of atypical heart attack

Only the initial stage of atypical infarction is characterized by unusual manifestations. Then he takes the usual course. The difficulty lies in its timely diagnosis and treatment. Despite the fact that atypical forms of infarction are not very common, this does not make them less dangerous to the health and life of the patient. Classification of myocardial infarction by localization of pain and atypical signs:

Form	Pain localization	Symptoms not typical of a typical heart attack	What can be confused?
peripheral	upper chest;	severe general weakness;	toothache;
	throat;	increased sweating;	angina;
	lower jaw;	dizziness;	scoliosis;
	left shoulder joint;	pressure reduction;	articular, muscular or neurological pathology
	subscapular region	signs of arrhythmia
Abdominal	Epigastric region with irradiation between the shoulder blades	vomiting without relief;	gastritis;
		bloated belly;	ulcer;
		diarrhea;	pancreatitis
		vomiting or bloody stools
asthmatic	No pain	inability to fully breathe;	cardiac asthma;
		the patient tends to sit down, taking a position with emphasis on the hands;	bronchial asthma
		clearly distinguishable gurgling in the chest;
		sticky sweat;
		cough with frothy pink sputum;
		blanching of the nasolabial triangle, hands and ears
Collaptoid or silent ischemia	No pain	a sharp drop in pressure;	Insufficiency of cerebral circulation
		severe weakness;
		fainting or fainting;
		visual impairment;
		cold sweat;
		weak pulse in the hands;
		signs of arrhythmia;
		dizziness
edematous	No pain	edema - from local on the legs to extensive (ascites);	chronic cor pulmonale;
		enlarged liver;	acute heart failure
		dyspnea;
		palpitations and interruptions
Arrhythmic	No pain	dizziness and darkness in the eyes;	AV heart block;
		fainting;	paroxysmal tachycardia;
		noise in ears;	atrial fibrillation
		cardiac arrhythmias
cerebral	No pain	flies before the eyes, darkening;	stroke;
		dizziness;	blockage of arteries in the brain
		nausea;
		severe weakness in the limbs
Erased	Weak pains	severe weakness and sweating;	Can be ignored by patients due to mild symptoms
		dizziness;
		tachycardia;
		shortness of breath

The asthmatic form of myocardial infarction occurs when a large area of the heart muscle with transmural damage is covered by ischemia. Necrosis can affect the areas of impulse conduction, which leads to a violation of myocardial contractility. The asthmatic form is more common than others, mainly in elderly patients. An important symptom is suffocation. The heart attack proceeds according to the type of pulmonary asthma and has an unfavorable prognosis.

cerebral form

A heart attack may have a course similar to a stroke. At the same time, the patient has all his signs - impaired speech, fainting, unconsciousness. These symptoms are transient, with cerebral infarction there are no functional and organic lesions of the brain. But they complicate the diagnosis of acute myocardial infarction. The picture is clarified by the ECG, blood biochemistry and a careful physical examination of the heart.

Other variants of atypical infarction

Atypical forms of myocardial infarction also include combined and painless. Combined can combine signs of other forms. Painless is the most insidious type of the disease. With this form of myocardial infarction, there is no pain signal, the only manifestations are short weakness or sweating. The patient can ignore these symptoms, as a result, myocardial infarction is diagnosed only on the ECG during a random examination.

Types of atypical heart attack by localization

Types of myocardial infarction are divided according to the localization of foci:

lateral myocardial infarction;
basal (lower), when necrosis affects both the superficial and deep layers;
rear;
front;
septal myocardial infarction.

According to the anatomy of the lesion and clinical signs, the heart attack is divided into:

transmural (all layers of muscle tissue are affected);
intramural (the inner muscle layer is affected);
subepicardial (a narrow strip of tissue near the endocardium of the left ventricle is exposed to ischemia);
subendocardial (a layer of tissue near the epicardium is susceptible to necrosis).

The most difficult to diagnose are lateral and posterior infarction. Together with the lateral area, the lower and upper parts of the heart can be affected, then the heart attack is called combined. With septal localization, the interventricular septum undergoes necrosis. This form is rare and poorly read on the ECG.

When ischemia covers the apex of the heart in a semicircle and simultaneously passes to the posterior and anterior walls of the left ventricle, they speak of circular myocardial infarction. Its main cause is thrombosis of the interventricular artery. According to clinical manifestations, it refers to subendocardial. It is this type of disease that most often occurs in senile patients with severe forms of atherosclerosis and hypertension.

Diagnosis of an atypical heart attack

Atypical variants of myocardial infarction are difficult to diagnose. Often, treatment is delayed, which subsequently leads to severe cardiac pathologies. The most reliable source is the electrocardiogram.

With different forms, it is necessary to differentiate a heart attack from other diseases, under whose symptoms it is hidden. Therefore, the patient is prescribed:

Ultrasound of the abdominal organs;
computed tomography;
brain encephalography;
blood chemistry;
blood clotting analysis.

Of particular difficulty in diagnosis is the arrhythmic form of a heart attack, which hides signs of an acute heart attack on the ECG. In this case, urgent measures are taken to eliminate the signs of arrhythmia, then the cardiogram is taken again.

The peculiarity of the abdominal form is that the patient takes pain in the abdomen for the manifestation of gastritis, ulcers or pancreatitis. He begins to self-medicate and misses the acute phase of myocardial infarction by going to the doctor when treatment does not help him. It is possible to distinguish an exacerbation of gastrointestinal diseases from a heart attack by the localization of pain. If the heart is the cause, then the pain will spread to the area above the diaphragm.

Since atypical forms of myocardial infarction develop against the background of existing cardiac pathologies, even unusual symptoms should be a reason to call an ambulance or see a doctor. Such heart attacks are characterized by a high mortality rate precisely because of the difficulty of diagnosis and delayed seeking medical help.

angina pectoris(Latin angina pectoris, synonymous with angina pectoris) is a disease, the most characteristic manifestation of which is an attack of pain, mainly behind the sternum, less often in the region of the heart. The clinical picture of angina pectoris was first described by V. Geberden. He noted the main features of pain in angina pectoris; pains appear suddenly when walking, especially after eating; they are short-term, stop when the patient stops. According to foreign data, angina in men is observed 3-4 times more often than in women.

Etiology and pathogenesis At present, it can be considered established that angina pectoris is caused by acute insufficiency of the coronary blood supply, which occurs when there is a discrepancy between blood flow to the heart and its need for blood. The result of acute coronary insufficiency is myocardial ischemia, causing a violation of oxidative processes in the myocardium and excessive accumulation of unoxidized metabolic products (lactic, pyruvic, carbonic and phosphoric acids) and other metabolites in it.

The most common cause of angina pectoris is atherosclerosis of the coronary arteries. Much less often, angina pectoris occurs with infectious and infectious-allergic lesions.

Provoke angina attacks emotional and physical stress.

Clinical picture

Angina pectoris is accompanied by discomfort in the chest area, which occurs when the blood supply to the heart muscle decreases. Usually with angina, a person feels: heaviness, pressure or pain in the chest, especially behind the sternum. Often the pain radiates to the neck, jaw, arms, back, or even teeth. Indigestion, heartburn, weakness, excessive sweating, nausea, colic, or shortness of breath may also occur.

Attacks of angina pectoris usually occur with overexertion, strong emotional arousal, or after a heavy meal. At these times, the heart muscle needs more oxygen than it can get through the narrowed coronary arteries.

An attack of angina pectoris usually lasts from 1 to 15 minutes, it can be weakened by calming down, sitting or lying down, putting a nitroglycerin tablet under the tongue. Nitroglycerin dilates blood vessels and lowers arterial pressure. Both of these reduce the heart muscle's need for oxygen and relieve an attack of angina pectoris.

Diagnostics Among the various methods for studying angina pectoris (indicators of lipid metabolism, the activity of AST and ALT, creatine kinase, lactate dehydrogenase and their isoenzymes, coagulograms, glucose and blood electrolytes), the diagnostic value of new markers of myocardial damage - troponin-I and troponin-T should be especially noted. These are highly specific myocardial proteins, the determination of which can be used for late diagnosis of myocardial infarction, prognosis for unstable angina, detection of minimal myocardial damage (microinfarction) and identification of high-risk groups among patients with coronary artery disease. [source not specified 361 days]

The "gold" standard for diagnosing angina pectoris (as one of the forms of coronary artery disease) is currently considered coronary angiography. Coronary angiography is an invasive procedure that is essentially a diagnostic operation. [source not specified 361 days]

Also, according to the results of the ECG, ischemic changes can be recorded.

Treatment.

Conservative therapy for angina pectoris includes the appointment of:

prolonged nitrates

a combination of antihypertensive drugs (β-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics)

antiplatelet agents (acetylsalicylic acid preparations), statins.

Surgical treatment involves performing coronary artery bypass grafting (CABG) or balloon angioplasty for coronary artery stenting.

Myocardial infarction- one of the clinical forms of coronary heart disease, occurring with the development of ischemic necrosis of the myocardium, due to the absolute or relative insufficiency of its blood supply.

Classification

By stages of development:

The most acute period

Acute period

Subacute period

Scarring period

In terms of damage:

Large-focal (transmural), Q-infarction

Small-focal, non-Q-infarction

Localization of the focus of necrosis.

Myocardial infarction of the left ventricle (anterior, lateral, inferior, posterior).

Isolated apical myocardial infarction.

Myocardial infarction of the interventricular septum (septal).

Myocardial infarction of the right ventricle.

Combined localizations: posterior-inferior, anterior-lateral, etc.

Etiology

Myocardial infarction develops as a result of obstruction of the lumen of the vessel supplying the myocardium (coronary artery). The reasons can be (by frequency of occurrence):

Atherosclerosis of the coronary arteries (thrombosis, plaque obstruction) 93-98%

Surgical obturation (artery ligation or dissection for angioplasty)

Coronary artery embolization (thrombosis in coagulopathy, fat embolism, etc.)

Separately, a heart attack is distinguished with heart defects (abnormal origin of the coronary arteries from the pulmonary trunk)

Pathogenesis

There are stages:

Damage (necrobiosis)
Scarring

Ischemia can be a predictor of a heart attack and last for an arbitrarily long time. When compensatory mechanisms are exhausted, damage is said to occur when metabolism and myocardial function suffer, but the changes are reversible. The stage of damage lasts from 4 to 7 hours. Necrosis is characterized by irreversible damage. 1-2 weeks after the infarction, the necrotic area begins to be replaced by scar tissue. The final formation of the scar occurs after 1-2 months.

Clinical manifestations

The main clinical sign is intense pain behind the sternum (anginal pain). However, pain sensations can be variable. The patient may complain of discomfort in the chest, pain in the abdomen, throat, arm, shoulder blade, etc. Often the disease is painless. In 20-30% of cases with large-focal lesions, signs of heart failure develop. Patients report shortness of breath, unproductive cough. Often there are arrhythmias. As a rule, these are various forms of extrasystoles or atrial fibrillation.

Atypical forms of myocardial infarction

In some cases, the symptoms of myocardial infarction may be atypical. This clinical picture makes it difficult to diagnose myocardial infarction. There are the following atypical forms of myocardial infarction:

Abdominal form - symptoms of a heart attack are pain in the upper abdomen, hiccups, bloating, nausea, vomiting. In this case, the symptoms of a heart attack may resemble those of acute pancreatitis.

Asthmatic form - the symptoms of a heart attack are represented by increasing shortness of breath. The symptoms of a heart attack are similar to those of an asthma attack.

Atypical pain syndrome during a heart attack can be represented by pain localized not in the chest, but in the arm, shoulder, lower jaw, iliac fossa.

A painless form of a heart attack is rare. Such a development of a heart attack is most typical for patients with diabetes mellitus, in whom a violation of sensitivity is one of the manifestations of the disease (diabetes).

Cerebral form - the symptoms of a heart attack are dizziness, impaired consciousness, neurological symptoms.

There is an attack of severe pain in the area behind the sternum. In such cases, the diagnosis of the disease is carried out almost unmistakably, which allows you to immediately begin therapy for the pathological condition. It happens that myocardial infarction manifests itself absolutely atypical for the disease and patients experience a number of symptoms that sometimes resemble signs of diseases of the visceral organs. So, what are the atypical forms of myocardial infarction and how to determine them?

Factors contributing to the development of atypical forms of MI

Atypical forms of myocardial infarction occur mainly in elderly people with a genetic predisposition to atherosclerotic lesions of the coronary vessels. The development of an abnormal clinic of the disease is facilitated by a number of factors, including:

severe cardiosclerosis;
insufficiency of coronary circulation;
diabetes;
vascular atherosclerosis;
arterial hypertension;
experienced heart attacks in the past or the patient's history.

Options for the course of the disease

According to statistical studies, myocardial infarction, the development of which differs from the classical variant of the course of the disease, occurs in every tenth patient diagnosed with focal necrosis of the heart muscle. As a rule, such an ailment at the very beginning of its development is disguised as diseases of the visceral organs or proceeds almost asymptomatically, without a clearly defined pain syndrome.

Atypical forms of myocardial infarction include:

abdominal;
arrhythmic;
asthmatic;
collaptoid or painless;
asymptomatic;
peripheral;
edematous;
cerebral;
combined.

The abdominal form of myocardial infarction is typical for patients who develop necrosis adjacent to the diaphragm, which provokes the development of symptoms similar to those of disorders of the digestive tract. For this variant of the course of the disease, the following symptoms are characteristic:

pain in the abdomen, mainly in the epigastric region or under the right costal arch in the area of the projection of the liver and biliary tract;
severe nausea, vomiting;
intestinal flatulence;
pronounced bloating;
constipation or diarrhea.

Most often, abdominal infarction occurs under the guise of acute pancreatitis. It is possible to determine focal myocardial necrosis using an ECG study, as well as during a medical examination, when the tone of the muscles of the anterior abdominal wall and disturbances in the work of the heart in the form of a decrease in blood pressure and arrhythmia are diagnosed.

The arrhythmic variant of the disease is characterized by minimal manifestations of the pain syndrome during the development or disturbance of the conduction of the heart. In patients, signs of paroxysmal tachycardia, atrioventricular blockade and other pathological conditions come to the fore. Such symptoms should be taken very seriously and should not be forgotten to differentiate them from the arrhythmic form of MI.

The asthmatic form of myocardial infarction occurs mainly in the elderly, regardless of their gender. Often this variant of the disease is a recurrence of necrosis of the heart muscle, therefore, in this case, not a single minute can be lost. In patients, the disease begins with an attack of shortness of breath, which occurs on exhalation and is very similar to bronchial asthma. Shortness of breath is often accompanied by a cough that produces pink, frothy sputum.

Painless ischemia or collaptoid myocardial infarction is an atypical form of the course of the disease, which is characterized by disturbances in the functioning of the central nervous system, which are expressed in dizziness, fainting and visual disturbances. Painless myocardial infarction proceeds absolutely painlessly against the background of a sharp decrease in blood pressure, which makes it possible to suspect a myocardial infarction.

The painless variant of myocardial necrosis is rare. In most clinical cases, they suffer from elderly patients with diabetes mellitus. As you know, in the elderly and diabetics, the pain threshold is significantly reduced due to the death of receptors. It is with this pathological phenomenon that the occurrence of a painless form of myocardial infarction and the development of collaptoid conditions are associated.

The asymptomatic or erased form of the disease is the most insidious variant of the development of the disease, which is very difficult to diagnose in a timely manner, which leads to severe complications of the pathological condition and significantly undermines the health of the sick person. The asymptomatic form is characterized by the concealment of the main symptoms. The patient simply feels a slight malaise or loss of strength, while a real catastrophe occurs in his heart.

The disease in most cases is regarded as a manifestation of a common cold or overwork at work. Patients very rarely betray the significance of such a deterioration in their health. Therefore, they do not consider it necessary to seek qualified medical help.

Peripheral MI is characterized by the appearance of pain atypical for the disease, which occurs in places of possible irradiation without a focus of primary pain. For example, in many patients affected by a peripheral form of myocardial necrosis, the algic syndrome manifests itself in the throat and resembles a sore throat. Also, pain can be determined only in the lobe of the little finger or under the shoulder blade, without feeling it in the region of the heart.

The edematous form of myocardial infarction develops in patients with signs of heart failure. In such patients, against the background of relative well-being, swelling sharply occurs, first local, and then extensive. Massive edema is accompanied by increasing shortness of breath, an increase in the size of the liver and accumulation of fluid in the abdominal cavity.

The cerebral variant of the disease proceeds like cerebrovascular insufficiency. A sick person develops severe dizziness, which can lead to fainting. Sometimes patients are diagnosed with speech disorders and weakness in the limbs. Often there are symptoms such as nausea, vomiting, the appearance of dark circles before the eyes.

The cerebral form of myocardial infarction resembles the collaptoid variant of the disease, and can also be mistakenly regarded as a cerebral stroke.

Unlike ischemia of a section of the central nervous system, cerebral infarction does not cause functional and organic disorders of the brain.

Combined focal necrosis of the muscle tissue of the heart is rare in clinical practice. With this variant of the development of the disease, the patient has manifestations of several atypical forms of the pathological condition at once, which further complicates its diagnosis. The most common is considered a combined heart attack, when the patient complains of pain in the abdomen (a symptom of the abdominal form) and severe dizziness with clouding of consciousness (typical for the cerebral variant of the disease).

Unfortunately, sometimes even the most experienced doctors are not able to determine the combined form of an atypical heart attack. That is why there is a delay in the appointment of adequate treatment and the risks of developing complications of a heart stroke increase.

Features of diagnostics

Atypical variants of myocardial infarction are quite difficult to diagnose, which is explained by the clinical picture hidden or disguised as other pathological conditions at the beginning of the development of the disease. That is why all patients with suspected disorders in the work of the cardiovascular system need to record an electrocardiogram, which will determine the presence of zones of ischemia of the heart muscle.

ECG in small-focal myocardial infarction in the region of the apex and anterolateral wall of the left ventricle

The most difficult in terms of diagnosis is the arrhythmic form of focal myocardial necrosis, which is explained by the registration of arrhythmias on the ECG, which successfully masks the signs of a heart attack. In this regard, for any kind of arrhythmic disorders, specialists first relieve an attack of rhythm disturbance, and then record a repeated electrocardiogram of the heart to determine the true state of affairs.

Since atypical forms of myocardial infarction mimic various diseases of the internal organs, patients, in addition to the ECG, should undergo a series of studies to exclude or confirm the proposed diagnosis:

ultrasound examination of the abdominal organs;
computed tomographic examination of the body;
cerebro- or electroencephalography;

Due to circumstances, it is sometimes beyond the power of even an experienced cardiologist to diagnose an atypical heart attack in a timely manner. Therefore, it is not always possible to start anti-ischemic treatment in time, which allows limiting the area of necrosis.

What should be done when typical symptoms appear?

When symptoms appear that resemble the clinic of atypical variants of the course of myocardial infarction, you should not engage in self-diagnosis, and even more so self-treatment.

Even with the slightest suspicion of the occurrence of signs of necrosis of foci of the heart muscle, you should immediately seek qualified help and call an ambulance.

As a rule, after a medical examination, an ECG examination is prescribed for a patient with suspected cardiac dysfunction, which allows you to determine myocardial infarction and hospitalize the person in the intensive care unit.

Myocardial infarction is a dangerous damage to the heart, followed by the release of a necrotic zone. When an attack occurs, death occurs in 30% of cases. Especially dangerous is the period within a few hours after the onset of dangerous manifestations. If you notice severe pain in the area behind the sternum, discomfort is given to the arm, the lower jaw area, you need to call an ambulance. If the pain syndrome arose due to the development of a heart attack, it cannot be stopped with nitroglycerin. The patient is placed in a hospital, medical care is provided.

Myocardial infarction - damage to a significant area of the heart muscle as a result of circulatory disorders, which occurs due to arterial thrombosis. The area that does not receive blood gradually dies off. Usually, tissues begin to die after 20-30 minutes from the moment when the blood stops flowing into the organ.

A heart attack is characterized by severe pain behind the sternum, which cannot be stopped when taking standard analgesics. It gives to the arm, shoulder girdle, as well as to other areas of the body located in close proximity to the affected area. During the passage of the attack, patients feel an unreasonable feeling of anxiety. An attack can occur not only with strong psycho-emotional stress, but also with complete rest. The pain syndrome lasts from 15 minutes to several hours.

Classification

In medicine, there are several options for classifying myocardial infarction, taking into account a variety of factors, especially its course. In most cases, a typical form of myocardial infarction occurs. This disease is divided into the following subspecies:

Subepicardial. Necrotized cells are located mainly near the epicardium.
Subendocardial. The lesion manifests itself in the region of the endocardium.
Intramural. The necrotic area is located in the area of the myocardium. This is one of the most dangerous types of pathology, as the thickness of the heart muscle is affected.
Transmural. Part of the heart wall is necrotized. This is a large focal type of myocardial infarction. Most cases occur in males after the age of 50 years.

Classification of myocardial infarction includes methods for determining the form of infarction by the location of the lesion. If you do not conduct special diagnostic studies, it is very difficult to accurately determine the affected area. Sometimes, when an attack occurs, there are no signs of muscle damage, and there are other factors that make diagnosis difficult at the initial stages.

In most cases, large-focal myocardial infarction is observed. Sometimes at the beginning of the attack, the affected area is small, after a while it may increase. When a small-focal heart attack occurs, the disease is characterized by a moderate course, the risk of dangerous complications is reduced. If thromboembolism is not observed after an attack, the likelihood of heart failure, heart rupture, and aneurysm is reduced.

Among the varieties of this disease, such atypical forms of myocardial infarction are distinguished:

Abdominal. Often it is confused with an attack of pancreatitis, since the pain syndrome is mainly located in the upper abdomen. A person feels additional symptoms, such as nausea, increased gas formation, in some cases vomiting occurs, and hiccups are also possible.
Osmotic. It can be confused with the acute phase of the development of bronchial asthma, the attack is accompanied by shortness of breath, while a gradual aggravation of symptoms appears.
Atypical pain syndrome. It manifests itself in the jaw area, in the future the pain radiates to the arm, shoulder.
Asymptomatic. The painless form of myocardial infarction is extremely rare. It usually occurs in diabetics, the sensitivity of the nervous system of which is significantly reduced as a result of a chronic disease.
Cerebral. It is rare, but one of the most complex forms. Also applies to atypical forms of heart attack. There are signs of a neurological nature. Dizziness is noticeable, with untimely assistance, loss of consciousness is possible.

Focusing on the multiplicity, experts distinguish different types of myocardial infarction. Main varieties:

Primary.
Recurrent. Occurs within 2 months after the first attack.
Repeated. It appears more than 2 months after the onset of the first heart attack.

Types of heart attack

The area of necrosis is determined in relation to the depth of the lesion. Usually this parameter depends on the location of the affected area. According to the area of necrosis, various types of myocardial infarction are distinguished.

Small focal subendocardial

The affected area is characterized by small parameters, manifested in the lower segment of the heart muscle. The necrotic zone is small not only at the beginning of an attack, but is also diagnosed after neutralization of especially dangerous symptoms. When conducting an ECG, disturbances in the structure of the Q wave practically do not appear.

Small focal instrumental

In diagnostic studies on the ECG, Q wave disturbances are also not detected. The necrotic area is found in the inner part of the myocardium. This type of heart attack is one of the most dangerous, as it spreads over a large area. If medical measures are provided on time, doctors will be able to correct violations. This type of heart attack in case of recovery of the patient gives a minimum number of complications.

Large focal transmural

In medical practice, it is considered the most dangerous species, as it provokes a large number of deaths. In this case, the development of dangerous complications is possible. The affected area is a large part of the myocardium, while a significant segment of the heart muscle is necrotized. When performing an ECG, an altered QS wave is noted, which indicates the most severe form of the disease.

Large focal non-transmural

If an ECG is performed in a timely manner, an altered Q wave is detected. Despite the fact that the clinical picture looks less dangerous, there is a risk of complications, and in some cases a fatal outcome is also possible. A significant number of cardiomyocytes are necrotic, but the myocardium is not completely affected.

Phases and stages of the disease

In medicine, the classification of myocardial infarction is determined by the internal and external manifestations of this pathology. With the appearance of a macrofocal lesion, the following phases of myocardial infarction are distinguished.

Preinfarction

With timely access to a doctor, this diagnosis is made in half of the cases. Patients present with severe angina attacks that gradually worsen. Pathology is especially dangerous if the following manifestations occur:

A sharp decrease in body functions, which negatively affects the patient's well-being.
Insomnia, increased anxiety.
Rapid fatigue, often people are not able to perform even minimal activity.
Increased weakness, against the background of which irritability occurs.
Neither rest nor frequently used medicines help to overcome negative symptoms.

sharpest

In some cases, this phase is called ischemic. It lasts from half an hour to 2 hours. As a result, destructive processes occur in the tissues of the heart due to increasing ischemia. People feel severe pain that starts abruptly. When the pain syndrome manifests itself, unpleasant sensations are given to the shoulder, arm, jaw, sometimes appear in other areas of the body. In some cases, the manifestations of a heart attack are confused with others, which slows down the diagnosis, delays seeking medical help.

Acute

There is necrosis of the heart tissue. It continues for 2 days. During this time, the affected area becomes delineated, it is easy to identify it during the diagnosis. If a heart attack is not the first time, an increase in the affected area can occur within 10 days, sometimes longer. Perhaps the appearance of acute circulatory disorders, rupture of the heart muscle, the occurrence of blood clots, arrhythmias. In the acute stage of a heart attack, the body temperature rises, fever appears.

subacute

It is characterized by the replacement of the necrotic muscle area with connective tissue. Perhaps the development of heart failure, arrhythmia. There may be an aggravation of comorbidities. Respiratory problems develop, stagnation is possible, while maintaining optimal body temperature.

Postinfarction

With the passage of this stage of myocardial infarction, a process of scarring occurs. The end of this period occurs approximately 6 months after the acute attack. If the lesion is too large, the person's condition may worsen. Some patients who have had a heart attack suffer from a recurrence of this disease within 3 years. If there are no serious complications, an increase in physical activity is shown, there is a chance to restore the usual life activity. It is possible to normalize the rhythm of heart contractions, normal indicators appear in the blood test.

Depending on the form of a heart attack, the nature of the pain is different:

Feeling of distension.
Pain, classified as burning.
Squeezing.

In the most acute stage of myocardial infarction, any of these symptoms reaches a maximum intensity in a short period of time, lasting for several minutes or hours. Spasms are possible, but in most cases, pain does not decrease. The operation takes place without pain, which is due to the characteristics of a particular organism. If the pain does not go away for a long time, acute damage to a large area of \u200b\u200bthe myocardium is possible.

This phase of the disease is characterized by the following symptoms:

Drawing pain in abdomen, retching.
Strong shortness of breath.
Sometimes breathing becomes difficult.
Cold sweat breaks out.
Weakness develops rapidly. It is possible that the person was engaged in the usual work, then felt exhausted.
Increased anxiety.

Treatment after a heart attack

Treatment of a heart attack occurs in a hospital, as this disease is a threat to life. In case of detection of symptoms of any of the listed stages of myocardial infarction, it is necessary to call an ambulance. To determine the disease, to clarify the features of the pathology, an electrocardiogram is performed.

After recovery, discharge from the hospital, a long rehabilitation period is provided. People who have had a myocardial infarction should undergo sanatorium treatment, regularly visit a cardiologist, and use diagnostic methods when their condition worsens. The goal of therapy in the treatment of myocardial infarction is to reduce pain, prevent the spread of the lesion, and also eliminate the causes that caused the attack. The prognosis of the disease depends on the correctness of such therapeutic measures, the characteristics of the patient's body.

Tasks of therapy:

Restoration of blood circulation. If congestion is stopped in a timely manner, the prognosis for the patient's life improves.
Reducing the area of tissue subject to necrosis.
Pain reduction.
Prevention of the occurrence of other pathologies that manifest themselves against the background of a heart attack. With the help of medical, sometimes surgical methods, the likelihood of complications is reduced.

Many patients who are aware of the increased risk of heart disease are interested in what heart attacks are. When studying the types, stages of this disease, it is necessary to respond in a timely manner to the appearance of negative symptoms, seeking medical help. Signs of any form and phase of a heart attack are weakness, pain, shortness of breath, and increased sweating. To exclude the likelihood of developing a heart attack, to reduce its consequences, diagnostic measures are performed, symptomatic treatment is carried out.