Clinical Characteristics Of Walk-through Angina, Warm-up Angina And Myocardial Infarction Of Collateral Circulation Occlusion In The Same Infarction Zone And K_ATP Channel Blocker Interventional Effect

Objective: Coronary arteriosclerotic heart disease, called for short coronary heart disease, is one of epidemic diseases today. It is also the problem of the public health in the world. Nowaday, all over the world people pay close attention to the topic problem. It is reported that coronary heart disease is the first place in all diease death cause. Coronary heart disease is classified to five types that are asymptomatic myocardial ischemia, angina pectoris, myocardial infarction, ischemic cardiomyopathy and primary heart arrest. Clinical practice indicates that the typing standard can not satisfied with the clinical demand nowadays. The aim of the study is to explore the three special types of coronary heart disease which are a special type of ST segment elevation acute myocardial infarction and two special type of angina pectoris (walk-through angina and warm-up angina), and to make people know roundly the three special and rare types of coronary heart diseases.Methods and results1. Protection of warm-up angina to heart and the effects of KATP channel blocker on itPatients with the chronic stable angina who had positive exercise and was angiographically proven came into the study. They were divided into three groups according to the presence of diabetes and its treatment: 25 patients with the chronic stable angina only came into the NDM group, and 22 patients with diabetes came into the DMG group, and 22 patients with diabetes but on diet only came into the DMD group. The total number was sixty-nine. All the entry patients underwent sequential bicycle ergometer exercises test twice separated by 15min on the day of the study. We needed to investigate the changes of exercise duration (ED), the time to 1mm ST-segment depression (T-STD), maximum STD (mm) and the corresponding heart-rate systolic blood pressure product (RPP or ischaemic threshold, mmHg/min×102). Then the differences of these variable indexes among the three groups were compared. The results were as follows.1.1 In group NDM,all the analysed variables improved significantly during the second test (EX2) in comparison with the first test (EX1), and which showed that the ischaemic threshold was increased significantly(173.77±34.73 vs 199.23±37.07 mmHg/min×102,P<0.05) and the ED and T-STD were prolonged (546.04±103.78 vs 617.52±106.96s,P<0.05 & 385.64±92.34 vs 426.84±91.25s, P<0.05) , and the STDmax was reduced (2.06±0.37 vs 1.75±0.41mm, P<0.05).1.2 In group DMG,there was no difference in these analysed variables except T-STD between the first and second test (P>0.05).The T-STD in the second test was significantly longer than that in the first test (328.45±64.66 vs 363.00±81.48s, P<0.01).1.3 In group DMD, all analysed parameters improved significantly in the second test (EX2) in comparison with the first test (EX1). For example, the ischaemic threshold was increased(181.58±40.34 vs 204.51±30.91 mmHg /min×102, P<0.05),as well as the T-STD was not prolonged (366.95±86.93 vs 404.27±101.61s, P>0.05) and the STDmax was reduced (2.10±0.46 vs 1.79±0.38mm, P<0.05). However, the exercise duration (ED) had no the same behavior (P>0.05).2. Study of clinical characteristics and pathogenesis of walk-through angina28 cases of inpatients with walk-through angina (WTA) and 28 cases of stable angina pectoris (SAP) respectively were selected to the study, which were called WTA group and SAP group respectively. We summarized both patient's attitude and doctor's knowledge about the disease. At the same time, we observed the risk factors of coronary heart disease, clinical features, ECG performance, the results of heart ultrasound, the results of coronary angiography, treadmill exercise testing, and the ability of heart rate response in the two groups with coronary heart disease. The results were analysed and compared between the two groups. The results were as follows.2.1. According to the asking history, doctors and patients paid no attention to the importance of the disease. Before the diagnosis of WTA,they had been at least once misdiagnosed and/or missed diagnose in a hospital, and the rate of misdiagnosis and/or missed diagnosis was one hundred percent.2.2 Judging from the clinical manifestations, the symptoms of WTA patients were quite different from those suffering from SAP. The WTA patients felt typical angina pectoris with initial activities. As the activity continues, angina did not aggravate, but gradually reduced or even disappeard instead. Labour induced angina attacks and rest could relieve angina symptom rapidly in SAP patients.2.3 Heart ultrasound parameters: The number of LVEF and LVFS in the WTA group was lower significantly than those in SAP group (P<0.01). However, the number of E peak and A peak was no difference between the two groups (P>0.05).2.4 The results of CAG:Three bronch lesions, total occlusion lesions, type C lesions and the formation of collateral circulation of coronary artery in WTA groups were more than those in SAP group (P<0.01).2.5 The results of WTA group and SAP group exercise test indicated that ST-segment depression lasted for 512.43±46.49s and 591.03±5.27s (P<0.01); Number with ST segment depression of leads was 3.01±0.51 and 6.10±0.76 (P<0.01); Chronotropicresponse index (CRI ) was 0.48±0.05 and 0.74±0.07 (P<0.01); Maximal heart rate in movement was 124.32±6.89 beat /min and 145.35±5.25 beat/min (P<0.01); The metabolic cost of maximum exercise was 5.64±0.62 Mets and 4.87±0.48 Mets,respectively (P<0.01).2.6 Revascularization: More patients in WTA group were selected to revascularization, and more patients in SAP group were selected to drug treatment,P<0.01. 3. Clinical feature and pathogenesis and intervention strategy for acute ST segment elevation acute myocardial infarction which is not fitted for thrombosis therapy.Patients with old myocardial infarction (OMI) were selected to the study objects. When the patients with unstable angina pectors or/and acute left heart failure attack, glycerinum in hypoglossis administration could not relieve the symptom and the symptom lasted for more than thirty minutes and the level of ST segment elevation was still more than 0.2mv. Patients with reinfarction were excluded. 29 patients were selected to the study, which was called SAMI group. On the other hand, inpatients who were not used thrombosis with the first ST segment elevation AMI therapy were called control group. The two groups were treated with routine check-up and therapy. The pathogenesis, clinical manifestation, electrocardiogram (ECG) dynamic variation, the level of myocardial creatase, the level of troponin, the results of heart ultrasound, the characteristic of coronary artery angiography and the treatment of the two groups were compared and analyzed .The results were as follows:3.1 Patients in SAMI group were consistent with the diagnostic criteria of acute myocardial infarction (AMI). The clinical features manifested more symptoms of acute left cardiac failure and less symptoms of myocardial ischemia. ST segment variation appeared in infracted zone leads. However, the variation of T wave and Q wave were not observed variation remarkablely.3.2 The level of CPK,CPK-MB and TNI was lower in the SAMI group than those in AMI group after attack 6hours, 12hours, 24hours, 48hours, respectively, P<0.01.3.3 Heart ultrasound parameters: The number of left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), E peak and A peak in the SAMI group were lower significantly than those in AMI group, P<0.01.3.4 The results of coronary artery angiography (CAG) :Three bronch lesions, type B lesions, type C lesions and the formation of collateral circulation of coronary artery in SAMI group were more than those in AMI group, P<0.01.3.5 Revascularization: The majority of patients in SAMI group were selected to coronary artery bypass grafting (CABG) and the majority of patients in AMI group were selected to Percutaneous coronary intervention (PCI), P<0.01.Conclusion1. Exercise test can induce the warm-up angina in patients with stable angina pectoris. Warm-up phenomenon can also occur in patients with stable angina patients pectoris combined with diabete mellitus who are well-controlled with diet only for the blood glucose level.2. The KATP channel blocker glibenclamide can block the warm-up angina when it use for patients with coronary artery combined with diabete, which can block myocardial self protection.3. KATP channel is related to the happening of the warm-up angina mechnism. We should encourage the patients with SAP to considerable exercise in order to strengthen protection on ischemic myocardium.4. The clinical significance of acute ECG ST segment elevation in the same infarction zone in patients with OMI combined with acute left heart failure or/and unstable angina pectoris is that the infarction is a special type of acute myocardial infarction. Its pathogenesis is that collateral circulation in the infarction zone reduces remarkablely even stops completely. The clinical feature manifests more symptoms of acute left cardiac failure and less symptoms of myocardial ischemia.5. The variation of ECG is that elevated ST segment falls down to isoelectric level in infracted zone leads gradually and the variation of T wave and Q wave does not appeare remarkablely. The level of cardiac myocardial creatase raises up lightly. The thrombolytic therapy does not suit for this situation absolutely.6. The clinical characteristic of WTA is not typical of in Chinese and the clinical symptom is relative light. Patients feel typical angina pectoris with initial activities. But as the activity continues, angina does not show increase, it will gradually reduce or even disappear instead. Both doctors and patients pay no attention to the importance to the disease. This type of angina is easily missed diagnosis and misdiagnosised by clinicians.7. The excise test shows that the condition in patients with WTA is severer in myocardial ischemia and worse in the ability of heart rate response and the results of CAG shows that ressel lesions are severe and widespread and always two or three branch lesions in coronary arteries as well as there are obvious collateral circulation in patients with WTA. Obvious collateral circulation is one of the pathogenesis in the patients with WTA. Revascularization is reasonable selection for the patients with WTA.