Tokushukai Medical Group

Treatment of disorder

medical treatment

Angina Pectoris and Cardiac Infarct

Angina Pectoris and Cardiac Infarct are the most popular diseases among matured person. They are one of can’t-miss diseases. Especially at acute period hospital treating many emergency patients, most of them are the patient of Angina Pectoris or Cardiac Infarct. We will explain comprehensibly about Angina Pectoris and Cardiac Infarct.

Heart: Pumping blood out to entire body

Humans act with thinking. The power source for the activity is a heart. It is like Power generation plant or vehicle engine. Reason why humans can think, exercise, subsist is that heart is supplying enough energy in blood to acting internal organs in a body.

Heart is a pump circulating blood to internal organs of entire body. It supplies relentlessly red blood, received oxygen at lung, to internal organs of entire body. Because no organs will survive when oxygen supply stops. When heart stops beating, the supply of oxygen to entire body also stops. As no oxygen supplied to brain, human falls unconscious. A heart should never and ever stop beating. As explained, heart is a pump keep circulating blood to entire body.

Blood Vessel: Pathway of blood

Blood pumped out from heart flows in internal organs of all over entire body with mutually exclusive and collectively exhaustive, then come back to heart. As explained, blood vessel is an organ carrying the circulating blood. Blood amount in a body is consistent, and they are circulating in blood vessels of entire body. They are, therefore, called as circulatory organ for both heart and blood vessel.

What is Coronary Artery: Power source of heart?

Why does heart keep beating? Because red blood, with full of oxygen, is supplied to heart as well. Heart supplies blood to brain, muscle, liver, kidney and others, but it supplies blood to its own muscle to keep beating. A blood vessel which supply blood to heart muscle is called as Coronary Artery.

Coronary Artery comes from nearby position of main artery out from heart, and then it surrounds the heart. There exist a right coronary artery and a left coronary artery. Right coronary artery is positioned below the right ventricle of heart, underneath the left ventricle. Left ventricle is then separated into two branch vessels. Left anterior descending coronary is in front of left ventricle, circumflex branch is at rear of heart’s lateral side. Total three vessels, one right coronary artery, two left coronary arteries, supplies blood to heart equally. When abnormal incident occur at coronary artery, causes not enough power source to heart, it is called as Angina Pectoris or Cardiac Infarct. They are collectively called as Coronary Arterial diseases (CAD).

Angina Pectoris: Disease caused by poor circulation of blood in cardiac muscle

Heart pumped blood out roughly hundred thousand (100,000) times a day. Therefore, heart needs a fresh, oxygen-full blood all the times. Coronary Artery supplies blood to cardiac muscle becomes narrower or stuck, blood supply to heart comes lessor. It is called as Angina Pectoris, poor circulation of blood in cardiac muscle. However, function of cardiac muscle has not yet diminished entirely at this point. It is like yellow signal turned on. Most people call for chest pain, then will not do any labored exercise. People try to respond to poor circulation of blood with less burden to heart. But in case when stress is applied to heart again, similar chest pain repeats.

Turns into cardiac infarct when coronary artery stuck entirely

In case Coronary Artery stuck further completely, or becomes narrower rather quickly, cardiac muscle is dead, and resulted heart function decline. This is called as Cardiac Pectoris. Cardiac Pectoris appeared suddenly at most case, however there is a case where disease appears unconsciously. Depend upon area and severity of dead cardiac muscles, it is expected for dangerous irregular heart beat or extreme decline of heart functionality, or may cause death in emergency.

Arterial sclerosis is a major factor for coronary artery.

As mentioned earlier, Angina Pectoris or Cardiac Infarct occurs when cardiac Artery is getting to stuck or stuck. The main reason for such occurrence is Arterial Sclerosis. Arterial Sclerosis is an abnormal incident for blood vessel. It may occur by, separate from advancing age, diabetes, dyslipidemia, elevated blood pressure, kidney disease, cigarette smoking, lifestyle habit, obesity, and constitution of person. There is a case where walls of coronary artery become gradually narrower by arterial sclerosis, or blood become suddenly hardened then stuck in narrowed coronary artery.

Arterial Sclerosis of Cardiac Artery

What is variant angina pectoris with no coronary artery?

The cause of Angina pectoris is generally arterial sclerosis on coronary artery, but in merely case, it occurs by Variant Angina Pectoris. Unlike coronary artery becomes gradually narrower, it works usually in normal, but coronary artery is suddenly jerked then get narrowed (contraction), then causes symptom of angina pectoris. This is called as variant angina pectoris. Sudden chest pain is a typical symptom. Chest pain may not be caused by physical exercise, but variant angina pectoris causes chest pain just before sleep at night or occurs without having any foretaste. Especially it is being said that variant angina pectoris occurs among young women.

Symptom of Angina Pectoris and Cardiac Infarct

Typical symptom of angina pectoris and cardiac Infarct are listed below.

Chest Pain
This is the most common symptom. Pains at front left chest to epigastrium. The most common symptom is like knotting, immotile pain on chest. It is likely occurring when walking up steps, doing physical exercise, or even when applying sudden stress to heart unconsciously, like when bathing or in washroom. Taking a rest ease the pain little bit, but sometimes ictal event remains for longer time, once started. In case pain is getting stronger, it may possibly turn into cardiac Infarct.
Closeness
It occurs when heart functionality declined. Or in case when stress is applied to heart without having chest pain, closeness is being noticed. If it is getting stronger, breathing difficulty, ill complexion may happen so that it becomes fatal.
No symptom
There is a person with no symptom at all. This is seen among aged personnel and persons in diabetes. This symptom can be seen in the case where coronary artery becomes gradually narrower, so that the other coronary artery assists.
Other Symptom
There is also the case that a person who is suffered with abdominal pain and omalgia is affected by angina pectoris or cardiac infarct.
Severe Case: fainted, shocked, arrest of breathing
In case the acute cardiac infarction, it shows several symptoms so that there might exist a fatal one.

Visit the office immediately when noticed any symptoms.

Most of the people may visit a hospital when chest pains. But it will not the case for all of them are in angina pectoris or cardiac infarct. On the other hand, there is a case that they are unable to visit hospital with the fear for the medical test. At last in taking pains on the chin too much, they must call for ambulance. Else, there is a case in not negligible that if they are hospitalized much earlier, it must not get too bad. But there is a case that arterial sclerosis of coronary artery has advanced without any symptoms so that patient has emergency transported due to sudden chest pain.

Correspondence at Hospital visiting

Corresponding procedure at medical organization may differ by the symptoms when visiting the hospital.

In emergency
Like feel a pain in chest, hard to breathe, or falls on the street, there are several cases but for the time-critical case like angina pectoris or cardiac infarct, imminent correspondence, like medical test then clinical treatment, in time-sensitive is inevitable. Cardiac Electrogram, Chest X-Ray, Cardiac Ultrasonography, Blood Test, then Coronary Angiography are proceeded, and clinical treatment has proceeded. Whilst these tests, with observing the entire physical condition, medical treatment with artificial breathing, intra-aortic balloon pump, and Cardiopulmonary Ancillary device may apply simultaneously, when necessary, for assisting entire physical condition.
Visit with reservation
For persons visiting hospital with no emergency, like chest pains in the past, hurts sometimes but not now, being told as angina pectoris by Cardiac Electrogram, we try to conduct medical tests as soon as possible upon request.

Diagnose with the combination of several tests

As the tests for angina pectoris or cardiac infarct, we conduct Electrocardiogram, Chest X-Ray, Blood Test and Coronary Angiography. In case other disease is suspicious, we may apply CT (Computed Tomography)-Test, and Abdominal Ultrasonography Test as well.

Electrocardiogram

Electrocardiogram records an electric signal from beating heart. It is hard to know everything from the record, but there sometimes is a case that Electrocardiogram record shows an abnormality when cardiac muscle has a shortage of oxygen and is accompanied by cardiac infarct.

Person with continued seizure
Able to diagnose whether there is, Angina Pectoris, Cardiac Infarct, portion of bad heart, and/or irregular heartbeat. As the matter of fact, Electrocardiogram is not a versatile equipment, but there is a case where no abnormality is recorded depend on the position and area of impaired heart.
Person with no seizure
There is an unidentified case. But it likely identifies occasionally whether Cardiac Infarct had occurred in the past.
Load Electrocardiogram

Although having a chest pain when climbing upstairs or running but with no pain in everyday, there sometimes is a case where Electrocardiogram check at medical check or in still and calm at hospital shows normal waves. In this case, taking certain exercise to apply load to heart may find an abnormality in Electrocardiogram record. Taking Electrocardiogram while exercising, like climbing up or down stairs or peddling a bike, is called Load as Electrocardiogram.

In anyway, electrocardiogram check is a simple test so that it can diagnose whether there is an angina pectoris or cardiac infarct but unable to diagnose where in coronary artery and how severe pathological abnormality occurs are still unknown. This check is best for screening the symptom. Of course there is a case where load electrocardiogram cannot make a decision.

24 hours Holter Electrocardiogram

We may ask patient, who have chest pain sometimes or seizure occur in early morning, to take Electrocardiogram for 24 hours. It can analyze 24 hours electrocardiogram changes without hospitalization. Electrocardiogram change at midnight seizure or category and severity of irregular heartbeat can be diagnosed. Although angina pectoris or cardiac infarct is revealed with this test, it becomes a help for diagnosis.

Chest X-Ray Test

Angina pectoris or cardiac infarct cannot be revealed by Chest X-Ray test. But as same as Electrocardiogram, it is simple and easy test and sometimes very useful. Especially, when the chest pain is not caused by heart, for example caused by lung or costal bones, Chest X-Ray test is very useful. For the heart condition, for example the size of heart or whether lung blood become stasis, can be checked in certain level. We can judge, roughly, the degree of heart debilitation.

CT Test
The cutting-edge Contrast Enhanced CT (CECT) can draw up the detail of coronary artery condition, and it is simple and easy to use even at out-patient department, and become useful to screening up. Also, it can tell, status of aorta, heart shape, lung condition in detail. It is therefore to find out other chest pain diseases than angina pectoris or cardiac infarct.

Coronary Artery by 320 row Contrast Enhanced CT

Heart Ultrasonography Test

With touching the breast, doctor finds the several things, like shape and movement of heart, shape of heart valve and regurgitation, and if something is compressing heart. In case of cardiac infarct, it can take a hold on the ingravescence in heart movement, like a serious cardiac infarct make a hole in one’s heart, or bleeding from heart.

Blood Exam
It is hard to diagnose cardiac infarct or angina pectoris from only blood exam. But in case of acute cardiac infarction, leucocyte, CPK, LDH values are increased at blood exam. It is therefore help for diagnose if it is resulted in cardiac infarct, or when it turns into the cardiac infarct. The cause of angina pectoris or cardiac infarct is an arterial sclerosis, therefore diagnose of diabetes, dyslipidemia, and kidney diseases are necessary and they work as screening for the patients.
Coronary Artery Contrast Study

The cause of angina pectoris or cardiac infarct is an abnormal change of coronary artery so that it is necessary for a final diagnose to check which coronary artery has changed and how seriously ill on coronary artery by coronary artery contrast study. This is the final test and the beginning of medical treatment for Angina Pectoris or cardiac pectoris. Long and thin tube (Catheter) about 2mm diameter is inserted into arteria, moving it to nearby heart, then insert to the entry of coronary artery. Contrast agent is transfused and X-ray it. When the inner cavity of coronary artery is stuck at entry, x-ray photo shows it ends in the middle. Nowadays, it becomes possible to insert the catheter from one’s wrist, resulted the test becomes safe and easy to do in one day.

Medical Exam had not been conducted except for some extraordinary reason in the olden times, but now the exam itself becomes easy and simple to conduct. Medical Exam lasts only for 15 minutes in average, and after the completion of exam, perform astrict on insert point for about three hours, then being released from hospital in a same day. In case of having chest pains, or breath shortness continued so that angina pectoris or cardiac infarct is suspicious in electrocardiogram check, Coronary Artery Contrast Study must be done immediately.

Coronary Artery Contrast Study picking out stuck severity of pathological abnormality.

With this exam, which part of coronary artery and how severely stuck, or coronary artery is about to stuck, can be picked up. With knowing the position and severity of pathological abnormality in coronary artery, doctor can grasp the degree and severity of Angina pectoris or cardiac pectoris of the patient. Then in accordance with the result, it is decided that what medical treatment should be done.

In case no abnormality finds out by Coronary Artery Contrast Study, but still chest pains.

There might be a case where Coronary Artery Contrast Study has conducted in suspicious of angina pectoris but unable to find any abnormality. Chest pain can be produced by irregular heart beat (abnormal cardiac rhythm), lung infarction, elevated blood pressure, or else, like gastroesophageal disease, lung disease. Or person who shows no abnormality in any medical exam may rarely exist. Doctor begins the explanation from the point which patient feels comfortable, but if worries are continued, please consult with doctor.

There is an abnormal case with no symptom at all.

Symptom is a patient’s description. It does not mean that all these descriptions correspond to angina pectoris, or pathological change severity of cardiac infarct, and/or degree of severity. When disease abnormality has progressed chronically and gradually at coronary artery, patients in diabetes or aged individuals likely have no symptom. On the contrary, persons with no symptom have an risk of having sudden cardiac infarct or angina infarct attack, and likely become severe.

Medical treatment selection differs on urgency

There are two major causes for the stuck in Coronary Artery. The one is a case where hardened blood suddenly stuck, i.e. acute cardiac infarction. In this case, stuck blood vessel should be widened by emergency surgical treatment. The other is a case where blood vessel has been gradually stuck from the past, i.e. angina pectoris. There is a case that it is better to start medical treatment as soon as possible depend upon stuck position in coronary artery or severity degree. Of course, angina pectoris or coronary artery are not necessarily possible to judge. We conduct best appropriate medical treatment for each patient while observing every single patient’s, pathological abnormality of coronary artery, heart condition, and overall physicals.

Is it possible to select “No medical treatment”?

In case of angina pectoris, work or daily life must be limited due to chest pain, but even if one is spending daily life with enough care, there is a case where the burden on heart is unconsciously placed, and in that case chest pain or feeling of oppression is recognized. Even worse is a cardiac episode (cardiac infarct). It is not uncommon story that a person in energy yesterday suddenly fall. Even if the case is without episode, heart is weakened gradually then turns to coexist chronic cardiac failure, abnormal cardiac rhythm, or valve disease. It is recommended that when certain abnormality is noticed, visit the office at earlier as possible.

Three basic principles in Coronary Artery disorder treatment

Several treatment methods can be considered depend on patients condition and degree of pathological abnormality on coronary artery.

The principles of the treatment are:

Particularly, there is drug therapy, catheter treatment (intervention), and surgical treatment.

Mainly use abortive medicine for drug therapy

There is a case where degree of pathological abnormality in coronary artery is minor, or location of pathological abnormality does not affect so much to heart. Medicine used for coronary artery disease is the drug to dilate a coronary artery, to prevent coronary artery from blood being stuck, and to relieve a burden from heart. They are all preventive drugs. There is a drug (Nitro Pens) to take when ictal occur. This is a method as emergency escape, so that it is very dangerous to spend a life with taking Nitro Pens every day. For not bringing Nitro Pens around, it is important to have medical treatment.

Nitrous Acid Agent (Nitrates R, Nitro Pens)
This has an immediate effectivity when ictal occur. It has an effect to dilate a coronary artery, and to relieve burden from heart with expanding entire body vessels.
Calcium Blocker (Herbessa, Adalat)
This is a drug to take for preventive purpose, and it’s effective. The drug has a function to prevent coronary artery constriction and broaden it. Especially, it prevent coronary artery constriction in atypical angina.
β Blocker (Tenormin, Tor Ming, Artist)
The drug to restrain heart beating for relieving heart burdens, and to prevent from angina pectoris or cardiac infarct even if having poor circulation of blood to coronary artery. This drug may decrease blood pressure or slower the pulse.
Aspirin (Buffer Phosphorus 81, Bias Aspirin)
This is a drug for preventing blood from matting. This prevent coronary artery from thrombogenic.
Panaldine, Plavix
This is also a drug for preventing blood from matting. It is a potent agonist, but side effect (platelet depletion, etc.) has also reported so that careful dosing is requested.

Catheter Treatment less burden for patient

This treatment has started 20 years ago. This becomes common treatment because treatment is conducted using small tube so that it gives less burden to patient. Inserting tube to the artery at the base of arm or foot, and making it to reach coronary artery at heart. Then ballooning coronary artery at narrowed inner cavity to broaden the coronary artery. There is a stent treatment which inserts metal net into blood vessel.

What is Balloon Treatment?
  • Catheter

  • • When balloon is blow-up

Balloon Treatment by catheter
  • Normal blood vessel
  • Blood vessel about to stuck
  • Blow hard balloon up in the blood vessel
  • Blown-up vessel
What is a stent?

A net is thinly collapsed to insert into blood vessel.

When blown up balloon from inside, net in shape remains in the vessel.

Stent Treatment using catheter
  • Normal Blood Vessel
  • Blood vessel about to stuck
  • Blow metal net inside the vessel
  • Blown-up vessel with net inserted

Coronary Artery Bypass Surgery, jumps over stuck portion

Picking up own blood vessel, then bypass stuck coronary artery to make reduced blood stream of coronary artery improved. Bypass vessel, using the internal mammary artery (blood vessel in the back of sternal plate), radial artery (blood vessel at thumb side of forearm), (greater saphenous vein) vein on the foot surface, gastroepiploic artery (blood vessel around stomach), is inosculated to coronary artery on heart. This method is older than catheter surgery, this has used from 30 years ago. Nowadays, it becomes more common method to conduct Off Pump Bypass Surgery to reduce patients’ burden. Catheter surgery is subject to internal medicine surgery but, Coronary Artery Bypass Method is subject to surgery department.

Catheter Treatment or Coronary Artery Bypass Surgery

Since Catheter Treatment has less burden to patient, it is recommended to make Catheter Treatment as first preference, if disease can be cured by Catheter Treatment. However, Catheter Treatment has a certain limitation. Nowadays, treatment result of mass patient data from Drug Therapy, Catheter treatment, Surgery cure, becomes unveiled. Based on these result data, treatment guideline for angina pectoris, coronary artery has been published in Japan as well as overseas.

Surgery recommended patient is a person that:

Practically speaking, it is judged from location and degree of pathological abnormality of coronary artery. The selection of Catheter Treatment or Coronary Artery Bypass Surgery are made by attending doctor, to be explained patients, and patients’ family member. There are many cases that are difficult to select Catheter Treatment or Coronary Artery surgery. It is important to decide after consulting with attended doctors’ opinion and explanation. In case if getting confused, it is recommended to have second opinion from another doctor’s comment.

Surgical timing may differ depend upon clinical condition

There is a case, depend upon patient clinical condition, where urgent surgery is inevitable, better to have surgery sooner as possible, or having surgery after an interval.

When urgent surgery is inevitable
This is a case of having chest pain suddenly and going into a decline relentlessly, or heart performance goes into a decline extremely to threat of life. i.e. a case diagnosed as acute cardiac infarction or unstable angina pectoris.
Better to have surgery sooner as possible
For all patients in angina pectoris, or cardiac infarct, we recommend to have surgery as soon as possible, even though there is no burden and symptom is stable currently.
Having surgery after interval
Postoperative healing becomes good if surgery is conducted when entire body status is in good condition, especially for coronary artery bypass surgery. Although heart performance goes into a decline by cardiac infarct, if in a recovering stage, it is better to have surgery after interval. Or, it’s better to conduct surgery when patient get recovered from catching a cold, or having a fever as a communicable disease like inflammation of the lungs. But in case when heart condition is getting worse, or when getting worse at anytime, it is better not to wait for the surgery.

Case fatality rate on surgery is 10% at emergency.

It is reported that the case fatality rate on Coronary Artery Bypass surgery in Japan is 2%, and the same on emergency coronary artery bypass surgery is 11%. There is a case that the patient survives but have a severe complicating disease.

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