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

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

The asthmatic form of myocardial infarction has a very unfavorable course and often ends in death.

Differential diagnostic signs of myocardial infarction

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

Myocardial infarction, allergic and infectious-toxic shock. Severe chest pain, shortness of breath, drop in blood pressure are symptoms that occur during anaphylactic and infectious-toxic shock. anaphylactic shock can occur with any drug intolerance. The onset of the disease is acute, clearly associated with the causative factor (injection of an antibiotic, vaccination to prevent an infectious disease, administration of anti-tetanus serum, etc.). Sometimes the disease begins 5-8 days from the moment of iatrogenic intervention and 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 given above. Differentiation is all the more difficult because with allergic and infectious-allergic shock, non-coronarogenic myocardial necrosis with gross ECG changes, leukocytosis, increased ESR, hyperenzymemia of AST, LDH, HBD, CPK and even CF CPK can occur. Unlike a typical myocardial infarction, such patients on the ECG do not have a deep Q wave, much less a QS complex, or discordant changes in the terminal 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 end-stage chronic renal failure. In acute pericarditis, the subepicardial layers of the myocardium are often involved in the process.

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

ECG data helps in diagnosis. Pi pericarditis has symptoms of subepicardial damage in the form of ST interval elevation in all 12 generally accepted leads (there is no discordance characteristic of myocardial infarction). The Q wave in pericarditis, unlike myocardial infarction, is not detected. The T wave in pericarditis can be negative; it becomes positive after 2-3 weeks from the onset of the disease. When pericardial exudate appears, 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 during myocardial infarction, they are clearly associated with breathing and coughing and do not have the typical irradiation of myocardial infarction. A productive cough is characteristic of pneumonia. The onset of the disease (chills, fever, pain in the side, pleural friction noise) is not at all typical for myocardial infarction. Physical and radiological changes in the lungs help diagnose pneumonia. The ECG with pneumonia may change (low T wave, tachycardia), but there are never changes reminiscent of those with myocardial infarction. As with myocardial infarction, with pneumonia one can detect leukocytosis, an increase in ESR, hyperenzymemia of AST, LDH, but only with myocardial damage does the activity of HBD, LDH1, and CPK MB increase.

Myocardial infarction and spontaneous pneumothorax. With pneumothorax, severe pain in the side, shortness of breath, and tachycardia occur. Unlike myocardial infarction, spontaneous pneumothorax is accompanied by a tympanic percussion tone on the affected side, weakened breathing, and x-ray changes (gas bubble, lung collapse, displacement of the heart and mediastinum to the healthy side). ECG indicators in spontaneous pneumothorax are either normal, or a transient decrease in the T wave is detected. There is no leukocytosis or increase in ESR in pneumothorax. Serum enzyme activity is normal.

Myocardial infarction and chest contusion. With both diseases, severe chest pain occurs and shock is possible. Concussion and contusion of the chest lead to myocardial damage, which is accompanied by elevation or depression of the ST interval, negativity of the T wave, and in severe cases, even the appearance of a pathological Q wave. Anamnesis plays a decisive role in making the correct diagnosis. The clinical assessment of a chest contusion with ECG changes should be quite serious, since these changes are based on non-coronarogenic 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 and unbearable. But, unlike pain from myocardial infarction, they disappear when the patient “freezes” in a forced position, and sharply intensify when turning the body and breathing. Nitroglycerin and nitrates are completely ineffective for osteochondrosis. the effect of analgesics is striking. With thoracic “radiculitis,” a clear local pain is determined in the paravertebral points, less often along the intercostal spaces. The number of leukocytes, ESR, enzymological parameters, ECG are within normal limits.

Myocardial infarction and herpes zoster. The clinical picture of herpes zoster is very similar to that described above (see description of the symptoms of radicular syndrome in osteochondrosis of the thoracic spine). Some patients may experience fever in combination with moderate leukocytosis and an increase in ESR. ECG and enzyme tests, as a rule, often help exclude the diagnosis of myocardial infarction. The diagnosis of herpes zoster becomes reliable from the 2-4th day of illness, when a characteristic vesicular rash appears along the intercostal space.

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 precardiac region, arrhythmia, and symptoms of shock. Acute left ventricular failure complicates the course of many heart diseases, including cardiomyopathies, valvular and congenital heart defects, 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 acute left ventricular failure syndrome occurs during a hypertensive crisis; (2) when it occurs in persons who have previously had a myocardial infarction and suffer from angina pectoris; (3) when suffocation occurs in patients with any rhythm disturbance, especially with tachysystole for no reason; (4) for the first or repeated 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.

LEADING SYMPTOM – ACUTE ABDOMINAL PAIN, DROP IN BLOOD PRESSURE

Myocardial infarction and acute cholecystsopancreatitis. In acute cholecystopancreatitis, as in the gastralgic version of myocardial infarction, severe pain occurs 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 upward and to the right, into the back, and can sometimes be encircling. Their combination with nausea and vomiting is natural, and an admixture of bile is detected in the vomit. Palpation determines pain at the point of the gallbladder, projections of the pancreas, positive symptoms of Kehr, Ortner, Mussy, which is not typical for myocardial infarction. Abdominal bloating and local tension in the right upper quadrant are not typical for myocardial infarction.

Leukocytosis, increased ESR, hyperfermentemia 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 case of myocardial infarction, one should focus on high levels of enzyme activity of CPK, MV CPK, and HBD.

The ECG may change in acute cholecystopancreatitis. This is a decrease in the ST interval in a number of leads, a weakly negative or biphasic T.N.K. wave. Permyakov described, using morphological material, large-focal myocardial damage in patients with acute cholecystopincreatitis, more often in cases of severe pancreatic necrosis. During their lifetime, these patients complained of intense abdominal pain, dyspeptic disorders, and collapse. ECG changes were infarct-like. The activity of serum enzymes, including CPK and CPK MB, sharply increased. These data were confirmed by V.P. Polyakov, B.L. Movshovich, G.G. Savelyev when observing patients with acute pancreatitis, cholecystitis in combination with diabetes mellitus. These data were defined as non-coronarogenic, metabolic, caused by the direct toxic effect of proteolytic enzymes on the myocardium, an 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 a leading factor in death.

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

With a perforated stomach ulcer, the symptoms change 2-4 hours from the moment of perforation. In patients with perforated gastroduodenal ulcers, symptoms of intoxication appear; the tongue becomes dry, the facial expression changes, its features become sharper. The abdomen becomes retracted and tense, the symptoms of irritation are positive, the “disappearance” of hepatic dullness is determined by percussion, and air under the right dome of the diaphragm is detected by X-ray. Body temperature may be low-grade in both diseases, as well as moderate leukocytosis during the first day. An increase in the activity of serum enzymes (LDH, CPK, CPK MB) is characteristic of myocardial infarction. The ECG for a perforated gastric ulcer usually does not change during the first 24 hours. The next day, changes in the end part are possible due to electrolyte disturbances.

Myocardial infarction and cancer of the gastric cardia. With cardia cancer, intense pressing pain in the epigastrium and under the xiphoid process often occurs, 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 weakly negative) in leads III, avF, which serves as a reason for diagnosing small-focal posterior myocardial infarction.

Unlike myocardial infarction in case of cardia cancer, epigastric pain naturally recurs daily and is associated with food intake. ESR increases in both diseases, however, the dynamics of the activity of the enzymes CK, MB CPK, LDH, GBD is characteristic only of myocardial infarction. In case of cardia cancer, the ECG is “frozen”; it cannot determine the dynamics characteristic of myocardial infarction. The diagnosis of cancer 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, epigastric pain appears and blood pressure drops. However, epigastric pain with nausea. vomiting and hypothermia are more typical for food poisoning. Diarrhea does not always occur with foodborne illness, but it never occurs with myocardial infarction. The ECG during food toxic infection either does not change, or during the study “electrolyte disturbances” are determined in the form of a trough-shaped downward shift of the ST interval, a weakly negative or isoelectric T wave. Laboratory tests for food toxic infection show moderate leukocytosis, erythrocytosis (blood thickening), a slight increase in ALT activity , AST, LDH without significant changes in the activity of CPK, MV CPK, GBD, characteristic of myocardial infarction.

Myocardial infarction and acute disturbance of mesenteric circulation. Epigastric pain and a drop in blood pressure occur in both diseases. The difficulties of differential diagnosis are aggravated by the fact that thrombosis of mesenteric vessels, like myocardial infarction, usually affects elderly people with various clinical manifestations of coronary artery disease and arterial hypertension. If blood circulation in the mesenteric vascular system is impaired, pain is localized not only in the epigastrium, but throughout the entire abdomen. The abdomen is moderately distended, auscultation does not reveal the sounds of intestinal peristalsis, and symptoms of peritoneal irritation may be detected. To clarify the diagnosis, a survey x-ray of the abdominal cavity should be performed and determine the presence or absence of intestinal motility and gas accumulation in the intestinal loops. Impaired mesenteric circulation is not accompanied by changes in 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 aneurysm of the abdominal aorta. In the abdominal form of dissecting aortic aneurysm, in contrast to the gastralgic variant of myocardial infarction, the following signs are characteristic (Zenin V.I.): the onset of the disease with chest pain; wave-like nature of the pain syndrome with irradiation to the lower back along the spine; the appearance of a tumor-like formation of elastic consistency, pulsating synchronously with the heart, the appearance of a systolic murmur above this tumor-like formation; increase in anemia.

When interpreting the symptom “acute epigastric pain” in combination with hypotension when making a differential diagnosis with myocardial infarction, one must keep in mind more rare diseases. acute adrenal insufficiency; rupture of the liver, spleen or hollow organ due to injury; syphilitic tabes 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-coronarogenic myocardial necrosis may occur with thyrotoxicosis, leukemia and anemia, systemic vasculitis, hypo- and hyperglycemic conditions. The pathogenesis of non-coronarogenic myocardial necrosis lies in the imbalance between the myocardial need for oxygen and its delivery through the coronary artery system. With thyrotoxicosis, metabolic demand sharply increases without adequate provision. With anemia, leukemia, diabetes mellitus (comatose states), severe metabolic disorders occur in the cardiomyocyte. Systemic vasculitis leads to severe disruption 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 symptoms of the underlying disease, pain in the heart, sometimes severe, and shortness of breath are noted. Data from laboratory studies are not very informative in differentiating non-coronary necrosis from myocardial infarction of atherosclerotic origin. Hyperfermentemia LDH, LDH1, HBD, CPK, CPK MV are caused by myocardial necrosis as such, regardless of their etiology. An ECG with non-coronarogenic myocardial necrosis reveals changes in the terminal part - depression or, less commonly, elevation of the ST interval, negative T waves, with subsequent dynamics corresponding to non-transmural myocardial infarction. An accurate diagnosis is established based on all the symptoms of the disease. Only this approach makes it possible to methodically correctly assess the actual cardiac pathology.

Myocardial infarction and cardiac tumors (primary and metastatic). With heart tumors, persistent intense pain in the precordial region, resistant to nitrates, heart failure, and arrhythmias may appear. The ECG shows a pathological Q wave, ST interval elevation, and a negative T wave. Unlike myocardial infarction, with a heart tumor there is no typical ECG evolution; it is low-dynamic. Heart failure and arrhythmias are refractory to treatment. The diagnosis is clarified by careful analysis of clinical, radiological and echocardiographic data.

Myocardial infarction and post-tachycardia syndrome. Post-tachycardia syndrome is an ECG phenomenon expressed in transient myocardial ischemia (ST interval depression, negative T wave) after stopping the tachyarrhythmia. This symptom complex must be assessed very carefully. Firstly, tachyarrhythmia can be the onset of a myocardial infarction, and an ECG after its relief often only reveals infarct changes. Secondly, an attack of tachyarrhythmia disrupts hemodynamics and coronary blood flow to such a degree that it can lead to the development of myocardial necrosis, especially with initially defective coronary circulation in patients with stenosing coronary atherosclerosis. Consequently, the diagnosis of post-tachycardia syndrome is reliable after careful observation of the patient, taking into account the dynamics of clinical, echocardiographic, and 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, and 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 clinical picture of myocardial infarction, and there is no characteristic ECG dynamics.

Cardiologist

Higher education:

Cardiologist

Saratov State Medical University named after. 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. “Core patients” are well aware of this and are guided by this symptom. But even doctors are sometimes at a loss when a heart attack manifests itself with syndromes that are not characteristic of it. What do you need to know about an atypical heart attack in order to recognize it in time and not “endure” it on your feet?

What is an atypical form?

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

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

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 through the blood. The cause is coronary spasm, embolism (blockage of a blood clot) of the coronary arteries, anemia, surges in blood pressure.

Forms of atypical heart attack

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

Form	Localization of pain	Symptoms not typical of a typical heart attack	What can it be confused with?
Peripheral	upper chest;	severe general weakness;	toothache;
	throat;	increased sweating;	angina;
	lower jaw;	dizziness;	scoliosis;
	left shoulder joint;	decreased blood pressure;	joint, muscle or neurological pathology
	subscapular region	signs of arrhythmia
Abdominal	The epigastric region with irradiation between the shoulder blades	vomiting without relief;	gastritis;
		bloated stomach;	ulcer;
		diarrhea;	pancreatitis
		vomiting or bloody stools
Asthmatic	No pain	inability to breathe properly;	cardiac asthma;
		the patient tries to sit down, taking a position with emphasis on his hands;	bronchial asthma
		clearly discernible gurgling in the chest;
		sticky sweat;
		cough with foamy pink sputum;
		paleness of the nasolabial triangle, hands and ears
Collaptoid or silent ischemia	No pain	a sharp drop in pressure;	Cerebrovascular insufficiency
		severe weakness;
		fainting or pre-fainting;
		visual impairment;
		cold sweat;
		weak pulse in the hands;
		signs of arrhythmia;
		dizziness
Edema	No pain	swelling - from local on the legs to extensive (ascites);	chronic pulmonary heart disease;
		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
		heart rhythm disturbances
Cerebral	No pain	spots before the eyes, darkening;	stroke;
		dizziness;	blockage of cerebral arteries by a blood clot
		nausea;
		severe weakness in the limbs
Erased	Mild pain	severe weakness and sweating;	May be ignored by the patient due to mild symptoms
		dizziness;
		tachycardia;
		difficulty breathing

The asthmatic form of myocardial infarction occurs when ischemia covers a large area of the heart muscle with transmural damage. Necrosis can affect areas of impulse conduction, which leads to impaired myocardial contractility. The asthmatic form is more common than others, mainly in elderly patients. An important sign is suffocation. A heart attack occurs like pulmonary asthma and has a poor prognosis.

Cerebral form

A heart attack can have a course similar to a stroke. In this case, the patient exhibits all its symptoms - speech impairment, fainting, unconsciousness. These symptoms are transient; with cerebral infarction there are no functional or organic lesions of the brain. But they make it difficult to diagnose acute myocardial infarction. The picture is clarified by an 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 features of other forms. Painless is the most insidious type of disease. With this form of myocardial infarction, there is no pain signal; the only manifestations are short-term weakness or sweating. The patient may ignore these symptoms, and as a result, myocardial infarction is diagnosed only on an ECG during a random examination.

Types of atypical infarction by location

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, infarction 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 subject to ischemia);
subendocardial (the layer of tissue near the epicardium is subject to necrosis).

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

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

Diagnosis of atypical heart attack

Atypical variants of myocardial infarction are difficult to diagnose. Treatment is often delayed, which subsequently leads to severe heart 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;
encephalography of the brain;
blood chemistry;
blood clotting test.

Particularly difficult in diagnosis is the arrhythmic form of infarction, which hides the signs of acute infarction on the ECG. In this case, urgent measures are taken to eliminate signs of arrhythmia, then the cardiogram is taken again.

The peculiarity of the abdominal form is that the patient mistakes abdominal pain for a manifestation of gastritis, ulcers or pancreatitis. He begins to treat himself and misses the acute period of myocardial infarction, turning to a doctor when treatment does not help him. You can distinguish an exacerbation of gastrointestinal diseases from a heart attack by the location of the pain. If the cause is the heart, 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 delay in seeking medical help.

Angina pectoris(lat.angina pectoris, synonym: angina pectoris) is a disease, the most characteristic manifestation of which is an attack of pain, mainly behind the sternum, less often in the heart area. The clinical picture of angina pectoris was first described by V. Heberden. He noted the main features of pain during angina pectoris: pain appears suddenly when walking, especially after eating; They are short-term and stop when the patient stops. According to foreign data, angina pectoris is observed in men 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 coronary blood supply, which occurs when there is a discrepancy between the blood flow to the heart and its need for blood. The result of acute coronary insufficiency is myocardial ischemia, which causes disruption of oxidative processes in the myocardium and excessive accumulation of under-oxidized metabolic products (lactic, pyruvic, carbonic and phosphoric acids) and other metabolites.

The most common cause of angina is atherosclerosis of the coronary arteries. Angina pectoris occurs much less frequently with infectious and infectious-allergic lesions.

Angina attacks are triggered by emotional and physical stress.

Clinical picture

Angina pectoris is accompanied by unpleasant sensations in the chest area, which occur when blood supply to the heart muscle decreases. Typically, with angina, a person feels: heaviness, pressure or pain in the chest, especially behind the breastbone. Often the pain is referred to the neck, jaw, arms, back or even teeth. You may also experience indigestion, heartburn, weakness, excessive sweating, nausea, colic, or shortness of breath.

Angina attacks usually occur during overexertion, strong emotional excitement, or after a heavy lunch. At these moments, the heart muscle requires more oxygen than it can receive through the narrowed coronary arteries.

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

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

Coronary angiography is currently considered the “golden” standard for diagnosing angina pectoris (as one of the forms of coronary artery disease). 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 following:

prolonged nitrates

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 and stenting of the coronary arteries.

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

Classification

By stages of development:

The most acute period

Acute period

Subacute period

Scarring period

By volume 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 myocardial infarction of the apex of the heart.

Myocardial infarction of the interventricular septum (septal).

Right ventricular myocardial infarction.

Combined localizations: posteroinferior, anterolateral, etc.

Etiology

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

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

Surgical obstruction (artery ligation or dissection during angioplasty)

Coronary artery embolization (thrombosis due to 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 heart attack and last indefinitely. When compensatory mechanisms are exhausted, they speak of damage when metabolism and myocardial function suffer, but the changes are reversible. The damage stage lasts from 4 to 7 hours. Necrosis is characterized by irreversible damage. 1-2 weeks after a heart attack, 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 chest pain (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. The disease is often painless. In 20-30% of cases with large-focal lesions, signs of heart failure develop. Patients report shortness of breath and nonproductive cough. Arrhythmias are common. 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. The following atypical forms of myocardial infarction are distinguished:

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

Asthmatic form - symptoms of a heart attack are represented by increasing shortness of breath. Symptoms of a heart attack resemble 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, or iliac fossa.

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

Cerebral form - symptoms of a heart attack include dizziness, disturbances of consciousness, and 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 accurately, which allows immediate treatment of the pathological condition. It happens that myocardial infarction manifests itself completely atypically 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 identify them?

Factors contributing to the development of atypical forms of MI

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

severe cardiosclerosis;
coronary circulatory insufficiency;
diabetes;
vascular atherosclerosis;
arterial hypertension;
the patient has experienced heart attacks in the past or has a history of heart attacks.

Variants of the course of the disease

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

Atypical forms of myocardial infarction include:

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

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

abdominal pain, 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. Focal myocardial necrosis can be determined 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 functioning of the heart in the form of decreased blood pressure and arrhythmia are diagnosed.

The arrhythmic variant of the disease is characterized by minimal manifestations of pain during the development or disturbance of cardiac conduction. In patients, signs of paroxysmal tachycardia, atrioventricular block and other pathological conditions come to the fore. Such symptoms should be taken very seriously and remember to differentiate them from the arrhythmic form of MI.

The asthmatic form of myocardial infarction occurs mainly in older people, regardless of their gender. Often this variant of the disease represents a relapse of necrosis of the heart muscle, so 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 producing pink, frothy sputum.

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

Painless variant of myocardial necrosis is rare. In most clinical cases, it affects elderly patients with diabetes. As is known, in older people 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 secrecy 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 pay attention to 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 suffering from a peripheral form of myocardial necrosis, algic syndrome manifests itself in the throat and resembles a sore throat. Also, pain can be detected only in the little finger or under the shoulder blade, without feeling it in the heart area.

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 suddenly 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 similar to cerebral circulatory failure. A sick person experiences severe dizziness, which can lead to fainting. Sometimes patients are diagnosed with speech disorders and weakness in the limbs. Symptoms such as nausea, vomiting, and the appearance of dark circles before the eyes often occur.

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 portion of the central nervous system, cerebral infarction does not cause functional or organic disorders of the brain.

Combined focal necrosis of cardiac muscle tissue is rare in clinical practice. With this variant of the development of the disease, the patient experiences 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 (abdominal symptom) and severe dizziness with clouding of consciousness (characteristic of 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. This is why there is a delay in prescribing adequate treatment and the risk of developing complications of a heart stroke increases.

Diagnostic features

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 cardiovascular system must record an electrocardiogram, which will determine the presence of zones of ischemia of the heart muscle.

ECG for small focal myocardial infarction in the area 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 arrhythmia on the ECG, which successfully masks the signs of a heart attack. In this regard, for any type of arrhythmic disorder, specialists first relieve an attack of rhythm disturbance, and then record a repeat electrocardiogram of the heart to determine the true state of affairs.

Since atypical forms of myocardial infarction imitate various diseases of internal organs, patients, in addition to an ECG, should undergo a number of studies to exclude or confirm the suspected diagnosis:

ultrasound examination of the abdominal organs;
computed tomography 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 on time, which allows limiting the area of necrosis.

What should you do if typical symptoms appear?

If symptoms appear that resemble the clinical picture of atypical variants of the course of myocardial infarction, you should not engage in self-diagnosis, much less self-medication.

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

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

Myocardial infarction is a dangerous lesion of the heart with subsequent release of a necrotic zone. When an attack occurs, death occurs in 30% of cases. The period within a few hours after the onset of dangerous manifestations is especially dangerous. If you notice severe pain in the area behind the sternum, discomfort radiates to the arm or lower jaw area, you need to call an ambulance. If the pain syndrome occurs due to the development of a heart attack, it cannot be relieved with nitroglycerin. The patient is admitted to a hospital and receives medical care.

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

A heart attack is characterized by severe chest pain that cannot be relieved by taking standard analgesics. It radiates to the arm, shoulder girdle, and other areas of the body located in close proximity to the affected area. During an attack, patients feel an unreasonable sense of anxiety. An attack can occur not only during strong psycho-emotional stress, but also during complete rest. The pain lasts from 15 minutes to several hours.

Classification

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

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

The classification of myocardial infarction includes methods for determining the form of infarction based on the location of the lesion. Unless special diagnostic studies are carried out, it is very difficult to accurately determine the affected area. Sometimes, when an attack occurs, there are no signs of muscle damage; there are also other factors that make diagnosis difficult in the initial stages.

In most cases, large focal myocardial infarction is observed. Sometimes at the beginning of an attack the affected area is small, but after a while it can increase. When a small focal infarction occurs, the disease is characterized by a moderate course, and 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, the following atypical forms of myocardial infarction are distinguished:

Abdominal. It is often confused with an attack of pancreatitis, since the pain syndrome is predominantly 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, and a gradual worsening of symptoms occurs.
Atypical pain syndrome. It appears in the jaw area, and then the pain radiates to the arm and shoulder.
Asymptomatic. The painless form of myocardial infarction occurs extremely rarely. Usually occurs in diabetics, whose nervous system sensitivity is significantly reduced as a result of a chronic disease.
Cerebral. It is rare, but one of the most complex forms. Also refers to atypical forms of heart attack. Signs of a neurological nature appear. Dizziness is noticeable; if assistance is not provided in a timely manner, loss of consciousness is possible.

Based 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 first heart attack.

Types of heart attack

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

Small focal subendocardial

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

Fine-focal instrumental

Diagnostic studies on the ECG also do not reveal Q wave abnormalities. 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 treatment is provided on time, doctors will be able to correct the violations. This type of heart attack, if the patient recovers, produces a minimal number of complications.

Large focal transmural

In medical practice, it is considered the most dangerous species, as it causes a large number of deaths. In this case, dangerous complications may develop. The affected area is a large part of the myocardium, and a significant segment of the heart muscle is necrotic. 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 death is possible. A significant number of cardiomyocytes become 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. When a large-focal lesion appears, the following phases of myocardial infarction are distinguished.

Pre-infarction

If you consult a doctor in a timely manner, this diagnosis is made in half of the cases. Patients experience severe attacks of angina, which gradually worsen. The 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.
Fatigue is easy, often people are unable to perform even minimal activity.
Increased weakness, accompanied by irritability.
Neither rest nor frequently used medications help overcome negative symptoms.

Acute

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 begins abruptly. When pain syndrome manifests itself, unpleasant sensations radiate to the shoulder, arm, jaw, and sometimes appear in other areas of the body. In some cases, the manifestations of a heart attack are confused with others, which delays diagnosis and delays seeking medical help.

Acute

Necrosis of heart tissue occurs. It continues for 2 days. During this time, the affected area becomes delineated and is easy to identify during diagnostics. If a heart attack does not appear for the first time, an increase in the affected area may occur within 10 days, sometimes longer. Acute circulatory disorders, heart muscle rupture, blood clots, and arrhythmias may occur. During the acute stage of a heart attack, body temperature rises and fever appears.

Subacute

It is characterized by the replacement of a necrotic area of muscle with connective tissue. Possible development of heart failure and arrhythmia. Concomitant pathologies may worsen. Problems with the respiratory system develop, congestion is possible, while optimal body temperature is maintained.

Post-infarction

When passing this stage of myocardial infarction, a scarring process 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 the disease within 3 years. If no serious complications arise, an increase in physical activity is indicated, there is a chance to restore normal life activities. It is possible to normalize the heart rate, and normal blood test results appear.

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

Feeling of fullness.
Painful sensations classified as burning.
Squeezing.

In the most acute stage of myocardial infarction, any of these symptoms reaches maximum intensity in a short period of time and continues for several minutes or hours. Spasms are possible, but in most cases the 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 the myocardium is possible.

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

Nagging pain in the abdomen, vomiting.
Severe shortness of breath.
Sometimes the breathing process becomes difficult.
Cold sweat appears.
Weakness develops sharply. It is possible that the person was doing his usual work, then felt exhausted.
Increased anxiety.

Treatment after a heart attack

Treatment of a heart attack occurs in a hospital, since this disease is life-threatening. If symptoms of any of the listed stages of myocardial infarction are detected, you must call an ambulance. To determine the disease and clarify the characteristics of the pathology, an electrocardiogram is performed.

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

Therapy goals:

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 susceptible to necrosis.
Reduced pain.
Prevention of the occurrence of other pathologies that manifest themselves against the background of a heart attack. With the help of medicinal and sometimes surgical methods, the likelihood of developing complications is reduced.

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