Atypical painless forms of myocardial infarction. Atypical forms of myocardial infarction

• Peripheral with atypical localization of pain: a) left-handed; b) left-scapular; c) laryngeal-pharyngeal; d) upper vertebral; e) mandibular.
• Abdominal (gastralgic).
• Asthmatic.
• Collaptoid.
• Edema.
• Arrhythmic.
• Cerebral.
• Erased (oligosymptomatic).
• Combined.

Atypical forms of myocardial infarction are most often observed in elderly people with severe symptoms of cardiosclerosis, circulatory failure, often against the background of recurrent myocardial infarction. However, only the onset of a heart attack is atypical; in the future, as a rule, myocardial infarction becomes typical.

Peripheral type of myocardial infarction with atypical localization of pain characterized by pain of varying intensity, sometimes increasing, not stopped by nitroglycerin, localized not behind the sternum and not in the precordial region, but in atypical places - in the throat (laryngeal-pharyngeal form), in the left hand, the tip of the left little finger, etc. ( left-handed), left shoulder blade (left-scapular), in the region of the cervicothoracic spine (upper vertebral), in the region of the lower jaw (mandibular). In this case, there may be weakness, sweating, acrocyanosis, palpitations, arrhythmias, and a drop in blood pressure. Diagnosis of this form of MI is based on the above symptoms, repeated ECG recording, taking into account the dynamics of its changes, and the detection of resorption-necrotic syndrome.

Abdominal (gastralgic) type of myocardial infarction observed more often with diaphragmatic (posterior) infarction, manifested by intense pain in the epigastrium or in the region of the right hypochondrium, the right half of the abdomen. At the same time, there is vomiting, nausea, bloating, diarrhea, paresis of the gastrointestinal tract with a sharp expansion of the stomach and intestines. On palpation of the abdomen, there is tension and tenderness of the abdominal wall. It is necessary to differentiate this form from pancreatitis, cholecystitis, appendicitis, intestinal obstruction, perforated stomach ulcer, food poisoning. The diagnosis of this form of MI is made on the basis of changes in the cardiovascular system (arrhythmias, a drop in blood pressure, deafness of heart sounds), ECG recordings in dynamics, resorption-necrotic syndrome, taking into account biochemical changes characteristic of the above acute diseases abdominal organs.

Asthmatic variant of myocardial infarction proceeds according to the type of severe suffocation, cough with foamy pink sputum (cardiac asthma, pulmonary edema) in the absence or low intensity of pain in the region of the heart. In this case, a gallop rhythm, arrhythmias, a drop in blood pressure are observed; as a rule, this variant occurs more often with repeated MI, as well as with MI against the background of severe cardiosclerosis, and almost always with papillary muscle infarction. To diagnose this variant, it is necessary to record an electrocardiogram in dynamics and identify resorption-necrotic syndrome.

Collaptoid variant of myocardial infarction- this is actually a manifestation of cardiogenic shock, characterized by the absence of pain, a sudden drop in blood pressure, dizziness, darkening of the eyes, the appearance of cold sweat.

At edematous form of myocardial infarction the patient develops shortness of breath, weakness, edema and even ascites relatively quickly, the liver enlarges - that is, acute right ventricular failure develops.

Arrhythmic variant of myocardial infarction manifested by a wide variety of arrhythmias (extrasystole, paroxysmal tachycardia or atrial fibrillation) or various degrees of atrioventricular blockade. Paroxysmal tachycardia completely masks the signs of MI on the ECG. The task of the doctor is to urgently stop the attack of paroxysmal tachycardia and record the ECG again.

Cerebral myocardial infarction due to the development of deficiency cerebral circulation. More often it is dynamic (dizziness, nausea, vomiting, confusion, transient weakness in the limbs), less often there is a stroke form with the development of hemiparesis and speech impairment (simultaneous thrombosis of the coronary and cerebral arteries).

Erased (malosymptomatic) form of myocardial infarction manifested by weakness, sweating, vague chest pains, which the patient often does not attach importance to.

Combined variant of myocardial infarction combines various manifestations of several atypical forms.

To diagnose atypical forms of myocardial infarction, it is necessary to carefully evaluate the clinical manifestations, the dynamics of ECG changes, resorption-necrotic syndrome, and echocardiography data.

A. Chirkin, A. Okorokov, I. Goncharik

Article: "Atypical forms of myocardial infarction, symptoms" from the section

It is always chest pain, sometimes accompanied by weakness and increased blood pressure. However, this is not always the case, and some forms of a heart attack may not only be accompanied by symptoms of poisoning, but also proceed with the absence of pain. What are these forms?

Species Features

Atypical forms of heart attack most often occur in the elderly and are expressed in the death of heart tissue due to poor blood circulation. Statistics show that women suffer from them less often by about 60%. As a rule, only the onset of a heart attack is atypical, after which it turns into a typical form.

Atypical forms are diverse, each of them has certain features.

• So, the peripheral form is characterized by the fact that the pain is felt not in the sternum, but in unusual places, for example, the tip of the little finger, the left shoulder blade and even the lower jaw.
• most often diagnosed with posterior myocardial infarction, and its diagnosis is difficult and is differentiated from pancreatitis, appendicitis, stomach ulcers and other diseases of the gastrointestinal tract.
• The asthmatic form most often manifests itself with repeated myocardial infarctions, as well as MI that has arisen due to severe.
• But the arrhythmic form is difficult to diagnose, because it hides the signs of a heart attack on the ECG.

The following video will tell about the features of typical and atypical myocardial infarctions:

Classifications

Atypical forms of myocardial infarction include:

• Peripheral with atypical localization pain symptoms:
  1. left-handed;
  2. left-scapular;
  3. laryngeal-pharyngeal;
  4. upper vertebral;
  5. mandibular;
• Abdominal.
• Asthmatic.
• Collaptoid.
• Edema.
• Arrhythmic.
• Erased.
• Combined.
• Cerebral form of myocardial infarction due to cerebrovascular insufficiency:
  • dynamic;
  • stroke;

According to the extent, the heart attack is divided into small-focal, with a small lesion, and which covers a large area of ​​​​the heart.

Causes

Atypical forms of myocardial infarction occur due to atherosclerosis, more precisely, due to atherosclerotic plaques leading to abnormal vasoconstriction. Due to the narrowing of the vessels, they cannot provide a normal blood flow to the heart, which gives rise to the development of necrosis of the tissues of the heart muscle.

There are several factors, that is, phenomena that contribute to the development of a heart attack. Perhaps the main factor is. The effect of tobacco is such that it constricts blood vessels and impairs the access of oxygen to the heart, and this, together with atherosclerosis, is guaranteed to lead to a heart attack. Other factors include:

• hypertension;
• obesity;
• diabetes;

Genetic predisposition also has a great influence. If the family has already had a myocardial infarction, then the chance of its formation increases to 60%.

Symptoms

Depend on the type of atypical form of myocardial infarction. For ease of perception, the forms and their symptoms are distributed in the table.

As you can see, the symptoms are very diverse, which makes it difficult to diagnose and treat the disease.

E. Malysheva will tell you more about the symptoms of different types of myocardial infarction in her video:

Diagnosis of atypical forms of myocardial infarction

Diagnosis largely depends on the shape of the myocardium. In addition to standard techniques such as history taking and physical examination, examinations are used:

1. general an-zy urine and blood, showing general state organism;
2. biochemical analysis of blood to identify risk factors;
3. studies of blood enzymes;
4. coagulogram;
5. echocardiography;
6. chest x-ray;
7. coronary angiography;

Depending on the results of these studies, treatment will be prescribed.

Treatment

Treatment of any atypical form of a heart attack is carried out in a hospital to monitor the patient's condition. It is based on compliance with therapeutic recommendations and drug treatment. In some cases, urgent surgical intervention is required.

Note! Folk treatment can only be carried out in conjunction with other methods!

Therapeutic

Therapy is to limit physical activity. The patient is obliged to comply with the hospital sleep and nutrition regimen, and any loads during this period. Loads also include emotional stress, which can aggravate the situation with treatment.

At the time of treatment is limited and. So, he is shown healthy and fresh food low in fat, salt. If necessary, the patient can wear a mask to supply oxygen through it.

Medical

Drug therapy should be prescribed at the first suspicion of a heart attack and consist of:

1. analgesics and nitrates that relieve pain;
2. sedative, to eliminate stressful situations;
3. beta-blockers that dilate blood vessels;
4. calcium antagonists that change the rhythm of the contractions of the agent;

After confirming the diagnosis, the following drugs can be added to the above drugs:

1. risk-reducing anticoagulants;
2. antiplatelet agents that thin the blood;
3. thrombolytics, which dissolve pre-existing blood clots;
4. beta blockers or ACE inhibitors.

These are universal types of drugs used to treat myocardial infarction. That is, any of these funds can be canceled or replaced when the diagnosis is confirmed.

Operation

Often, atypical forms of myocardial infarction are diagnosed too late and do not respond to drug therapy. Then the patient needs to:

• coronary angioplasty. During the procedure, an awning is placed in the affected vessel, which maintains the lumen in a normal state.
• Coronary artery bypass grafting. The most complicated operation, in which a bypass for blood flow is made from the patient's vein.

Other operations, such as balloon angioplasty, can also be used, but the listed techniques are the main ones.

Disease prevention

As with other forms of myocardial infarction, preventive measures are limited to preventing the development of heart disease. To do this, it is important to follow the standards of a healthy lifestyle, that is:

• Exercise daily and do cardio exercises, such as running or cycling. Classes should not be exhausting, but they should take at least 20 minutes.
• Cut down on eating fatty and fried foods, reduce the salt content in dishes.
• Include fresh vegetables and fruits, sea fish, lean meat in the diet.
• Normalize the mode of work and rest. You need to spend at least 7 hours sleeping.
• Control the level of cholesterol and blood pressure, reduce when they increase.

It will be useful to visit a cardiologist every 6 months, as well as to take urine and blood samples to monitor the condition of the heart.

The following video will tell you what foods to eat to reduce the risk of atypical heart attacks and other heart diseases:.

Forecast

It is difficult to predict the development of the situation, since much depends not only on the form of a heart attack, but also on the complications that have developed, the age of the patient and the response to drug treatment. A heart attack is a serious condition that often leads to death.

Statistics show that 10% of cured patients die within a year from developed complications. Mortality in hospitals is low, because there are all the necessary drugs to stabilize the patient.

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 is often with extensive transmural myocardial infarction.

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 allergic and infectious-allergic shock, non-coronary myocardial necrosis with severe ECG changes, leukocytosis, increased erythrocyte sedimentation rate, hyperenzymemia of AST, LDH, HBD, CPK, and even CF CPK. 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). Etiological factors of pericarditis - rheumatism, tuberculosis, viral infection(usually Coxsackie- or Echo-virus), diffuse diseases connective tissue. Pericarditis often occurs in patients with terminal chronic kidney failure. At acute pericarditis the subepicardial layers of the myocardium are often involved in the process.

In a typical variant, with dry pericarditis, dull, pressing, less often acute pains occur in the precordial region without irradiation to the back, under the shoulder blade, in left hand 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, leukocytosis, an increase in ESR, hyperenzymemia of AsAT, LDH can be detected in pneumonia, 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, there are severe pain in the chest, 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. In osteochondrosis with radicular pain syndrome in 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 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) in the event of the syndrome of acute left ventricular failure with 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. Savelyev when observing patients with acute pancreatitis, cholecystitis in combination with diabetes. These data were defined as non-coronary, metabolic, due to direct toxic effect on the myocardium of proteolytic enzymes, 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, MB 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 IHD, 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 signs 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. At acute poisoning there is direct toxic damage to myocardial cells. 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. Hyperfermentemia 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 disrupts hemodynamics and coronary blood flow to such a degree that it can lead to the development of myocardial necrosis, especially with an 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.

Atypical forms of myocardial infarction are characterized by symptoms atypical for this pathology, or their absence on initial stages. This is the danger of this pathology: not knowing about its existence, people continue to live in their usual rhythm, until one day the disease reaches its peak.

About what can provoke the development of the pathological condition in question, and how they can be recognized, will be described in this article.

Causes of atypical forms of heart attack - risk factors

The considered forms of cardiac pathology are often diagnosed in elderly people against the background of disorders in the circulatory system. Similar negative conditions can occur when the lumen of the vessel is blocked. blood clots, in case of fluctuations blood pressure, as well as at spasm of blood vessels.

The presence in the patient's medical history of the following pathologies increases the risk of an atypical form of myocardial infarction in the future:

• Significant errors in the functioning of the central nervous system.
• Formation of atherosclerotic plaques.
• Diabetes.
• Regular increase in blood pressure.
• Heart failure in advanced stages.
• Serious malfunctions of the stomach and / or intestines.
• Coronary artery disease.
• Cardiosclerosis, in which normal heart muscle cells are replaced by scar tissue that is inelastic in nature.
• Myocardial infarction in the past.

Classification of atypical forms of myocardial infarction - symptoms and clinical picture

The considered group of heart attacks is also referred to as oligosymptomatic, or silent heart attacks. All of them are united mild symptomatic picture at the initial stages of development.

There are the following types of atypical forms of myocardial infarction:

1. Abdominal or gastralgic. This pathology develops against the background of necrosis of the posterior section of the myocardium. Patients complain of severe pain under the right rib, or in the stomach area. Also concerned about nausea and vomiting, which are not associated with eating. Some patients have diarrhea, with a strong discharge of flatus. Others suffer from flatulence and constipation.
2. Hydropic. First, local edema appears. The patient gets tired quickly, constantly wants to sleep, suffocates. The veins in the neck are noticeably enlarged. In the future, fluid can accumulate in the lungs, as well as in the peritoneum, which is manifested by a feeling of discomfort in the chest. The parameters of the liver increase sharply.
3. Arrhythmic. A person feels failures in heart contraction: an increased heartbeat can be replaced by a feeling of "fading" of the heart. Pain behind the sternum is insignificant, or completely absent.
4. Asthmatic. The ailment under consideration in external manifestations is very similar to bronchial asthma. The cough is paroxysmal in nature, and is accompanied by the release of frothy sputum, which has a pink color. Pain in the region of the heart may or may not be present. Arterial pressure falls, and the heart beats in a frantic rhythm. Due to the inability to breathe normally, the patient develops a pathological fear of death.
5. Cerebral. It can appear in two forms. In the first case, the symptoms will be similar to those diagnosed during oxygen starvation of brain tissues. First, the patient noted the presence of pain in the eye area, temples. It will also be very dizzy, dark in the eyes. It often ends fainting. The overall picture is complemented by nausea and vomiting. The second form of cerebral atypical myocardial infarction is stroke. In practice, it is much less common, and is accompanied by a violation of motor activity and speech.
6. Collaptoid. In some medical sources, you can find another name for it - painless ischemia. Judging by the last name, the conclusion about the pain syndrome suggests itself - it simply does not exist. Often, pathology is observed in people after 50 years of age against the background of chronic heart failure. In such patients, frequent dizziness is noted (but not as severe as in the cerebral form of myocardial infarction), the feet are constantly cold, droplets of sweat appear on the forehead. Facial features also change: the nose acquires a pointed shape, the eyeballs tumble in, the skin becomes flabby, lose their elasticity. Arterial pressure is significantly reduced.
7. Asymptomatic, or erased myocardial infarction. This form the disease manifests itself to a minimal extent: a breakdown, slight chest pains, poor appetite or its absence, sweating. Sometimes even the doctor ignores the indicated symptoms, attributing everything to fatigue and vitamin deficiency. Erased myocardial infarction, by virtue of everything described above, is one of the most dangerous: as a rule, they learn about it at advanced stages, when it is no longer possible to save the patient's life.
8. Peripheral. Pain sensations in such situations are of an increasing nature and are localized anywhere, but not in places typical for cardiac pathologies: in the tip of the left little finger, left arm, left shoulder blade, throat, lower jaw, or in the neck and chest near the spinal column. In this regard, patients may initially seek advice from the wrong specialist: a surgeon, an otolaryngologist or a dentist. In addition to the pain syndrome, the patient may be disturbed by weakness, increased sweating, and heart rhythm disturbances.
9. Combined. Combines several forms at once. For example, disorders of the digestive tract (as in abdominal myocardial infarction) can be supplemented by dizziness, "flies" in the eyes, clouding of consciousness (as in cerebral myocardial infarction).

Localization of pain and discomfort in various forms and types of myocardial infarction

Features of the diagnosis of atypical forms of infarction, differential diagnosis

Diagnosis of the ailment in question begins with a detailed and careful history taking. The first diagnostic step is to record electrocardiograms. If there are attacks of arrhythmia, they should be stopped urgently, as this may affect the final diagnosis. After elimination of the arrhythmia, perform repeat ECG.

In addition to the ECG, other instrumental research methods may also be prescribed: heart ultrasound, computed tomography , as well as other measures at the discretion of the doctor.

Some atypical forms of myocardial infarction have symptoms in which it is problematic to immediately suspect cardiac pathology. Therefore, it is very important to timely distinguish the pathology under consideration from other diseases, and make an accurate diagnosis.

Complications of atypical forms of infarction, prognosis for life

It is generally problematic to predict how this disease will end, since this will be determined by several factors:

1. The patient's age. Older people have a lower chance of survival. This is due to the development of atherosclerosis, deterioration of metabolism, the presence of a number of chronic ailments with age.
2. The presence of exacerbations.
3. The quality and timeliness of therapeutic measures.
4. Varieties of atypical form of myocardial infarction. Asymptomatic and painless heart attacks have an unfavorable prognosis, and often end sadly for the patient. This is due to the absence of clear manifestations at those stages of the disease when specialized assistance can be provided.

The most common complications of atypical forms of myocardial infarction are:

• Disruptions in the heart rhythm. Such pathological condition is dangerous enough that it can cause death.
• heart aneurysm chronic nature. Its appearance is associated with the period of scar formation after myocardial infarction.
• Acute heart failure.

angina pectoris(lat. angina pectoris, synonymous with angina pectoris) - a disease, the most characteristic manifestation of which is an attack 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, coagulogram, 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 pectoris, 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:

1. Damage (necrobiosis)

2. 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. Such clinical picture complicates the diagnosis of 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, disorders of consciousness, neurological symptoms.