Several important key issues in the diagnosis of coronary heart disease
Expert introduction:
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Liu Gang
Chief physician, Director of Heart Heart of the First People’s Hospital of Aksu area.
He has been engaged in clinical work for 32 years, and has been committed to clinical medical treatment of cardiovascular medicine. He has taken the lead in carrying out one of the pioneers of cardiac intervention surgery in the Aksu area. He is the first batch of autonomous regions to involve qualifications. Intervention surgery and congenital heart disease intervention and arrhythmia and arrhythmia radio frequency discharge. There are thousands of personal coronary intervention examples, more than 100 incense intervention of the heart disease, and independently completed the first huge room septal defect, porous room septal defects, and ventricular interval defects after the completion of the southern Xinjiang. The level of coronary intervention surgery and console intervention is located in the southern Xinjiang.
Several important key issues in the diagnosis of coronary heart disease
1. Is the diagnosis of coronary heart disease established?
2. Determine what kind of treatment is required for coronary heart disease?
4. Emergency choice?
5. The timing of treatment?
6. What kind of therapy is selected
Whether the diagnosis of coronary heart disease is mainly based on evidence of whether there is myocardial ischemia.
Because the symptoms of coronary heart disease can be typical or not typical, the traditional diagnosis relies on typical symptoms and symptoms to dynamically change the electrocardiogram. In reality, many patients are not typical. Even if the symptoms are obvious or indeed, there is a diagnostic standard for ischemia. In addition, there are some diseases. ECG shows the same or similar of concentric myocardial ischemia, which will lead to misdiagnosis. Therefore, the first step must be correct to talk about how to treat.
First of all, during the diagnosis, we divide coronary heart disease into typical and unprecedented categories based on clinical manifestations and electrocardiogram.
Typical easy diagnosis, including acute myocardial infarction, unstable angina pectoris, and typical labor angina pectoris. Due to the obvious symptoms, these diseases have distinctive ECG and myocardial standard changes at each attack. Coupled with coronary arteries, it is easy to obtain a clear diagnosis.
Instead of typical coronary heart disease, there is a need for conclusive myocardial ischemia.
So, what are the conclusive evidence of myocardial ischemia? The most widely used and most commonly used criteria for the clinic is that the ECG ischemia is performed when the electrocardiography chest pain, and the electrocardiogram is often when there is no attack. This does have high accuracy, but from a rigorous perspective, this has obvious limitations. It was mentioned just now that only about 80%of patients with electrocardiogram are positive, or 20%are negative. For patients with symptoms or electrocardiogram, they need to find more conclusive evidence. These basiss have the following aspects: 1. Coronary arterial angiography shows that the main branch or large branch is severely closed or the distant blood flow is explicitly slowed down; 2. Coronary arterial blood flow reserve analysis (FFR) shows reduced blood flow pressure or microcirculation ischemia after stenosis. 3. Cardiac ultrasound or myocardial nucleo pouring appear to indicate ischemia. 4. In addition, the ECG motion load test has certain diagnosis significance for patients who are not typical and can tolerate certain physical activity (it is strictly forbidden to do this test for patients with rest and mild activity, that is, symptoms).
Some updated examinations prove that when symptoms are symptoms, myocardial ischemia is available, and then the myocardial activity is weakened and the energy metabolism of myocardium is reduced. Clear. Because there are more coronary heart disease diagnosed in clinical diagnosis, but many coronary heart disease actually does not have an exact evidence, so misdiagnosis is very common. Then when diagnosis is diagnosed, in addition to the typical symptoms, there are some, there are some, objective evidence is needed, one of which is at the same time as the chest pain, if the electrocardiogram manifestation of the corresponding myocardial ischemia can be found, then then It is also a powerful evidence. Secondly, during the sports tablet, some ECG performance can be induced to induce myocardial ischemia. So as some of the progress of this image science function, there are still some, (the examination is very objective, such as FFR, analyzing and diagnosis of coronary blood flow reserves. And to do heart ultrasound during myocardial ischemia, and find heart exercise to find heart exercise, find heart exercise, and find heart movement Weaken or disappear, etc., can be strongly explained, myocardial ischemia.
After clarifying the diagnosis of coronary heart disease, then the next important question is how to treat?
Two categories: treatment:
1. Conservative treatment includes basic treatment+drug treatment;
2. Surgical treatment, divided into 1. Surgical coronary artery bypass transplantation is called bridge; 2. Internal medicine intervention surgery, the full name is performed by pesom coronary internal forming surgery, referred to as PTCA+stent implantation.
As long as it is determined to have coronary heart disease, each patient must receive basic treatment of coronary heart disease+conventional drug treatment
Basic therapy is to intervene in the basic cause of the disease, quit smoking and restriction, control weight and diet, and control the original basic diseases such as hypertension, diabetes, hypercholesterol, atherosclerosis.
Conventional drug treatment is mainly to prevent thrombosis and resistance. The former prevents the formation of thrombosis in coronary arteries, which leads to myocardial infarction. The common first -line drugs are Aspirin, clopidogre, and tungrilo; the latter; the latter; the latter; the latter; the latter; the latter; the latter; the latter; To prevent the progress of porridge in the coronary vein, the growth of plaques is the most common fundamental cause of the vascular endothelial rupture, erosion, and the most common cause of thrombosis. The commonly used drugs are mainly Betine drugs. Guan Ting and so on. As long as the condition is mild and stable, conservative treatment is taken, and when an emergency occurs, the emergency treatment is selected according to the specific condition or thrombolytic treatment.
It is necessary to remind patients that interventional surgery is currently the fastest, the highest opening rate, and the most accurate treatment of closed blood vessels. Domestic and foreign treatment guidelines are stipulated that as long as it is an acute coronary syndrome Surgery), in hospitals with the ability to perform intervention surgery, all intervention surgery is preferred. Patients who are not suitable for thrombolytic therapy, such as age, have high risk of bleeding, acute non -ST can use emergency intervention surgery, and after surgery , TLML blood flow, the incidence of bleeding after treatment, and long -term prognosis are superior to thrombolytic treatment.
In addition to emergency (unstable angina pectoris and acute myocardial infarction), patients who still have obvious symptoms after conservative treatment need to evaluate the necessity of surgery. At this time The scope of ischemia; and whether the blood vessels of the lesions are blocked and the degree of narrowing; whether the blood vessels have a large range of blood vessels; The degree of danger, etc. In short, it is necessary to fully analyze the difficulty of various operations, risks, and benefits. Finally, the patient needs to use the test results to evaluate the patient to choose the surgical plan. Under normal circumstances, the advantages of intervention surgery due to small surgical trauma, low overall surgical risk, short time, high success rate, fast physical recovery, etc., have become the main surgical method of coronary heart disease.
Here are the principles of indications and technical selection of surgery.
Coronary heart disease surgery, the main purpose is to restore the blood supply to the heart and carry out blood reconstruction. There are several points in the general principle: 1. The more urgent the more you do it; 2. The larger the ischemia range 4. Stability of the symptoms, if the indicator is not strong, you can preserve the treatment for a period of time, and then make a decision based on the effect after treatment.
The following specifically introduces surgical indications. In the past, the important degree of blood vessel stenosis of coronary arteries was greater than 70%, which was a basis for intervention intervention, but this was not completely accurate.
In China ’s new guide, when expenditure is less than 90%of the coronary veins, interventional treatment must have evidence of ischemia. This is based on the result of evidence -based medical research. FFR confirmed that many coronary angiography results seem to be severe lesions with severe stenosis. Its remote blood flow has not decreased significantly, and there is no clear symptoms of ischemia in clinical practice. Stability Angina pectoris intervention has no significant benefit from the treatment of drugs. Based on the above two reasons, we need to determine the two issues clearly. Whether the coronary lesions are stable, that is, to determine whether the endothelial is thin, or the erosion, cracks, ulceration, mezzanine, etc. Clinically, exercise load tests, FFR, coronary ultrasound, and ECT, etc., are checking methods for cardiac ischemia for myocardium. For different patients, doctors need to choose targeted examinations. After comprehensive analysis, the corresponding surgical solution is formulated. For small branches at the end, the range of ischemia is small, or a sufficient side branch cycle has been established.
With the evidence of myocardial ischemia, do you need to do the most important intervention or the scope of ischemia? Diseases, coronary blood vessels. If the blood vessels have been blocked, then it is an important blood vessels, and the blood supply range is relatively large, then it must be reconstructed by blood transportation. There are two methods for reconstruction of the college, one is interventional treatment, and the formation of internal forming of the gangue artery cavity+stent implantation (referred to as a bracket), and the other is the coronary artery bypass transplantation, which is often said to be said to be Bridge. The principle of choice between the two is: When the vascular criminals are located on the left main and have calcification, or the left main drying area is involved, the difficulty of surgery and the high division of danger. The guide is recommended to bridge first. You can also consider intervention surgery as appropriate. Generally, hospitals suggest that you follow the guide to perform coronary transplantation. In addition, other parts can be considered for intervention surgery. When the lesion stenosis is between 70%and 90%, there is a need to support the support of ischemia. In addition to the comprehensive evaluation of the blood supply range, the evidence is insufficient or the risk is small, the drug is conservatively treated, and the intervention should be treated.
In addition, there are coronary spasm, microcirculation coronary heart disease, coronary arterial inflammation, thrombosis, cardiac syndrome, etc., which are mainly treatment of corresponding drugs. These diseases can also obtain a clear basis during diagnosis.
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The third question is the timing of treatment. Generally speaking, the sooner the treatment is better. When angina pectoris, treatment is given in time, and treatment is completely different than that after myocardial infarction occurs. Angina pectoris is that myocardial muscle is not necrotic. When the blood flow is completely recovered, the function of the heart can also shrink, and the function can be completely recovered. On the contrary, after acute myocardial infarction, some myocardial function has been completely lost, and often after treatment, it will often be treated after treatment. , Also left over the situation of incomplete heart function. In addition, if you have severe heart ischemia after the myocardial infarction or long -term severe heart, the heart has expanded significantly, the survival of the myocardial muscle, and the poor heart function, it will lose the best opportunity for blood transport reconstruction surgery. Therefore, the more critical illness, the greater the scope of ischemia, the more active intervention, the more scary, and it may also be in acute attacks. Some patients are due to the ischemia area and the infarction area is too large. Causes sudden heart death on the spot, or a lot of necrosis of myocardial muscle after myocardial infarction, and severe heart failure.
The above is the view of several key issues of the diagnosis and treatment of coronary heart disease. There are insufficient or dispatching places.
