3．不同類型心絞痛的藥物治療
�。�1)慢性穩(wěn)定型心絞痛：屬勞力型心絞痛；由氧耗量增加引起。運(yùn)動(dòng)時(shí)，血中兒茶酚胺增高，通過α受體使冠狀動(dòng)態(tài)收縮。所以在治療上除考慮除低氧耗量外，應(yīng)同時(shí)加用冠狀動(dòng)脈擴(kuò)張藥，以阻止狹窄的冠狀動(dòng)脈進(jìn)一步狹窄。常用硝酸酯類、鈣拮抗制，可單獨(dú)或聯(lián)合β阻滯劑。
�。�2)不穩(wěn)定型心絞痛：屬混合型心絞痛，增加氧耗量和自發(fā)性血管痙攣均可誘發(fā)，根據(jù)臨床表現(xiàn)和預(yù)后分為低危組和高危組。①低危組：包括新近出現(xiàn)的進(jìn)行性心絞痛或慢性穩(wěn)定型心絞痛突然加重，但無心電圖改變。這類患者預(yù)后較好，應(yīng)口服多種抗心絞痛藥物，硝酸酯、鈣拮抗劑或（和)β阻滯劑，并用阿司匹林。預(yù)防休息時(shí)心絞痛復(fù)發(fā)，可給硝酸甘油長效制劑或經(jīng)皮膚吸收的貼劑。②高危組：包括靜息心絞痛伴有或原有ST段改變。劇烈心絞痛持續(xù)時(shí)間較長的中間型急性冠狀動(dòng)脈缺血綜合征，其預(yù)后差，心肌梗死發(fā)生率和病死率高，應(yīng)入院積極治療。僅用鈣拮抗劑是不夠的，可加用靜脈滴注硝酸甘油和肝素，有主張用阿司匹林100～150mg/d，加用肝素鈣皮下給藥7500IU，每12h一次。有人報(bào)告用氨酰心安和肝素靜脈用藥治療不穩(wěn)型心絞痛，心肌梗死發(fā)生率和病死率顯著降低。
（3)變異型心絞痛：血管痙攣型心絞痛，鈣拮抗劑療效好。多中心研究硝苯吡啶或硫氮
酮較維拉帕米療效佳。硝酸酯與鈣拮抗劑合用比分別單用療效好。理論上β阻滯劑抑制β受體后，α受體興奮性加強(qiáng)，可使冠狀動(dòng)脈進(jìn)一步收縮，因此可加重變異型心絞痛的發(fā)作，有時(shí)α受體阻滯對變異型心絞痛有效。
有些冠狀動(dòng)脈痙攣患者，舌下含硝酸甘油或靜脈用硝酸甘油不能緩解，多見于冠狀動(dòng)脈造影時(shí)導(dǎo)管刺激或激發(fā)試驗(yàn)引起。可經(jīng)導(dǎo)管將小劑量硝酸甘油（25～200μg)直接注入痙攣的冠狀動(dòng)脈內(nèi)。
參考文獻(xiàn)
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