Skip to main content
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 2002 Dec;78(926):717–726. doi: 10.1136/pmj.78.926.717

Critical review of unstable angina and non-ST elevation myocardial infarction

P Sheridan 1, D Crossman 1
PMCID: PMC1757938  PMID: 12509688

Abstract

Within the coronary vasculature the progression of a stable atherosclerotic plaque into a vulnerable and ultimately unstable lesion leads to a cascade of events culminating in the clinical presentation of unstable angina or acute myocardial infarction. In recent years studies have provided new insights in to the pathology and natural history, stimulating advances in diagnosis, treatment, and management. The review discusses the progress made including the role of inflammation, cardiac biomarkers, antiplatelet therapy, and percutaneous intervention. Current issues of debate and future directions are also addressed.

Full Text

The Full Text of this article is available as a PDF (117.1 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Adderley S. R., Fitzgerald D. J. Glycoprotein IIb/IIIa antagonists induce apoptosis in rat cardiomyocytes by caspase-3 activation. J Biol Chem. 2000 Feb 25;275(8):5760–5766. doi: 10.1074/jbc.275.8.5760. [DOI] [PubMed] [Google Scholar]
  2. Alderman E. L., Corley S. D., Fisher L. D., Chaitman B. R., Faxon D. P., Foster E. D., Killip T., Sosa J. A., Bourassa M. G. Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff. J Am Coll Cardiol. 1993 Oct;22(4):1141–1154. doi: 10.1016/0735-1097(93)90429-5. [DOI] [PubMed] [Google Scholar]
  3. Antman E. M., Handin R. Low-molecular-weight heparins: an intriguing new twist with profound implications. Circulation. 1998 Jul 28;98(4):287–289. doi: 10.1161/01.cir.98.4.287. [DOI] [PubMed] [Google Scholar]
  4. Antman E. M., McCabe C. H., Gurfinkel E. P., Turpie A. G., Bernink P. J., Salein D., Bayes De Luna A., Fox K., Lablanche J. M., Radley D. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation. 1999 Oct 12;100(15):1593–1601. doi: 10.1161/01.cir.100.15.1593. [DOI] [PubMed] [Google Scholar]
  5. Antman E. M., Tanasijevic M. J., Thompson B., Schactman M., McCabe C. H., Cannon C. P., Fischer G. A., Fung A. Y., Thompson C., Wybenga D. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996 Oct 31;335(18):1342–1349. doi: 10.1056/NEJM199610313351802. [DOI] [PubMed] [Google Scholar]
  6. Barnett Paul G., Chen Shuo, Boden William E., Chow Bruce, Every Nathan R., Lavori Philip W., Hlatky Mark A. Cost-effectiveness of a conservative, ischemia-guided management strategy after non-Q-wave myocardial infarction: results of a randomized trial. Circulation. 2002 Feb 12;105(6):680–684. doi: 10.1161/hc0602.103584. [DOI] [PubMed] [Google Scholar]
  7. Berk B. C., Weintraub W. S., Alexander R. W. Elevation of C-reactive protein in "active" coronary artery disease. Am J Cardiol. 1990 Jan 15;65(3):168–172. doi: 10.1016/0002-9149(90)90079-g. [DOI] [PubMed] [Google Scholar]
  8. Bertrand M. E., Simoons M. L., Fox K. A., Wallentin L. C., Hamm C. W., McFadden E., de Feyter P. J., Specchia G., Ruzyllo W. Management of acute coronary syndromes: acute coronary syndromes without persistent ST segment elevation; recommendations of the Task Force of the European Society of Cardiology. Eur Heart J. 2000 Sep;21(17):1406–1432. doi: 10.1053/euhj.2000.2301. [DOI] [PubMed] [Google Scholar]
  9. Boden W. E., O'Rourke R. A., Crawford M. H., Blaustein A. S., Deedwania P. C., Zoble R. G., Wexler L. F., Kleiger R. E., Pepine C. J., Ferry D. R. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med. 1998 Jun 18;338(25):1785–1792. doi: 10.1056/NEJM199806183382501. [DOI] [PubMed] [Google Scholar]
  10. Boersma E., Pieper K. S., Steyerberg E. W., Wilcox R. G., Chang W. C., Lee K. L., Akkerhuis K. M., Harrington R. A., Deckers J. W., Armstrong P. W. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation. 2000 Jun 6;101(22):2557–2567. doi: 10.1161/01.cir.101.22.2557. [DOI] [PubMed] [Google Scholar]
  11. Boersma Eric, Harrington Robert A., Moliterno David J., White Harvey, Théroux Pierre, Van de Werf Frans, de Torbal Anneke, Armstrong Paul W., Wallentin Lars C., Wilcox Robert G. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet. 2002 Jan 19;359(9302):189–198. doi: 10.1016/S0140-6736(02)07442-1. [DOI] [PubMed] [Google Scholar]
  12. Bogaty P., Hackett D., Davies G., Maseri A. Vasoreactivity of the culprit lesion in unstable angina. Circulation. 1994 Jul;90(1):5–11. doi: 10.1161/01.cir.90.1.5. [DOI] [PubMed] [Google Scholar]
  13. Braganza D. M., Bennett M. R. New insights into atherosclerotic plaque rupture. Postgrad Med J. 2001 Feb;77(904):94–98. doi: 10.1136/pmj.77.904.94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Braunwald E., Antman E. M., Beasley J. W., Califf R. M., Cheitlin M. D., Hochman J. S., Jones R. H., Kereiakes D., Kupersmith J., Levin T. N. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2000 Sep;36(3):970–1062. doi: 10.1016/s0735-1097(00)00889-5. [DOI] [PubMed] [Google Scholar]
  15. Braunwald E., Antman E. M., Beasley J. W., Califf R. M., Cheitlin M. D., Hochman J. S., Jones R. H., Kereiakes D., Kupersmith J., Levin T. N. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina). Circulation. 2000 Sep 5;102(10):1193–1209. doi: 10.1161/01.cir.102.10.1193. [DOI] [PubMed] [Google Scholar]
  16. Buffon Antonino, Biasucci Luigi M., Liuzzo Giovanna, D'Onofrio Giuseppe, Crea Filippo, Maseri Attilio. Widespread coronary inflammation in unstable angina. N Engl J Med. 2002 Jul 4;347(1):5–12. doi: 10.1056/NEJMoa012295. [DOI] [PubMed] [Google Scholar]
  17. Burke A. P., Farb A., Malcom G. T., Liang Y. H., Smialek J., Virmani R. Coronary risk factors and plaque morphology in men with coronary disease who died suddenly. N Engl J Med. 1997 May 1;336(18):1276–1282. doi: 10.1056/NEJM199705013361802. [DOI] [PubMed] [Google Scholar]
  18. Burke A. P., Kolodgie F. D., Farb A., Weber D. K., Malcom G. T., Smialek J., Virmani R. Healed plaque ruptures and sudden coronary death: evidence that subclinical rupture has a role in plaque progression. Circulation. 2001 Feb 20;103(7):934–940. doi: 10.1161/01.cir.103.7.934. [DOI] [PubMed] [Google Scholar]
  19. Cannon C. P., Weintraub W. S., Demopoulos L. A., Vicari R., Frey M. J., Lakkis N., Neumann F. J., Robertson D. H., DeLucca P. T., DiBattiste P. M. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001 Jun 21;344(25):1879–1887. doi: 10.1056/NEJM200106213442501. [DOI] [PubMed] [Google Scholar]
  20. Chen L., Chester M. R., Crook R., Kaski J. C. Differential progression of complex culprit stenoses in patients with stable and unstable angina pectoris. J Am Coll Cardiol. 1996 Sep;28(3):597–603. doi: 10.1016/0735-1097(96)00203-3. [DOI] [PubMed] [Google Scholar]
  21. Chew D. P., Bhatt D. L., Sapp S., Topol E. J. Increased mortality with oral platelet glycoprotein IIb/IIIa antagonists: a meta-analysis of phase III multicenter randomized trials. Circulation. 2001 Jan 16;103(2):201–206. doi: 10.1161/01.cir.103.2.201. [DOI] [PubMed] [Google Scholar]
  22. Cohen M., Demers C., Gurfinkel E. P., Turpie A. G., Fromell G. J., Goodman S., Langer A., Califf R. M., Fox K. A., Premmereur J. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997 Aug 14;337(7):447–452. doi: 10.1056/NEJM199708143370702. [DOI] [PubMed] [Google Scholar]
  23. Collinson J., Flather M. D., Fox K. A., Findlay I., Rodrigues E., Dooley P., Ludman P., Adgey J., Bowker T. J., Mattu R. Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK) Eur Heart J. 2000 Sep;21(17):1450–1457. doi: 10.1053/euhj.1999.1995. [DOI] [PubMed] [Google Scholar]
  24. Davies M. J., Thomas A. Thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death. N Engl J Med. 1984 May 3;310(18):1137–1140. doi: 10.1056/NEJM198405033101801. [DOI] [PubMed] [Google Scholar]
  25. Emeson E. E., Robertson A. L., Jr T lymphocytes in aortic and coronary intimas. Their potential role in atherogenesis. Am J Pathol. 1988 Feb;130(2):369–376. [PMC free article] [PubMed] [Google Scholar]
  26. Falk E., Shah P. K., Fuster V. Coronary plaque disruption. Circulation. 1995 Aug 1;92(3):657–671. doi: 10.1161/01.cir.92.3.657. [DOI] [PubMed] [Google Scholar]
  27. Fox K. A., Cokkinos D. V., Deckers J., Keil U., Maggioni A., Steg G. The ENACT study: a pan-European survey of acute coronary syndromes. European Network for Acute Coronary Treatment. Eur Heart J. 2000 Sep;21(17):1440–1449. doi: 10.1053/euhj.2000.2185. [DOI] [PubMed] [Google Scholar]
  28. Galis Z. S., Sukhova G. K., Lark M. W., Libby P. Increased expression of matrix metalloproteinases and matrix degrading activity in vulnerable regions of human atherosclerotic plaques. J Clin Invest. 1994 Dec;94(6):2493–2503. doi: 10.1172/JCI117619. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Giroud D., Li J. M., Urban P., Meier B., Rutishauer W. Relation of the site of acute myocardial infarction to the most severe coronary arterial stenosis at prior angiography. Am J Cardiol. 1992 Mar 15;69(8):729–732. doi: 10.1016/0002-9149(92)90495-k. [DOI] [PubMed] [Google Scholar]
  30. Goldstein J. A., Demetriou D., Grines C. L., Pica M., Shoukfeh M., O'Neill W. W. Multiple complex coronary plaques in patients with acute myocardial infarction. N Engl J Med. 2000 Sep 28;343(13):915–922. doi: 10.1056/NEJM200009283431303. [DOI] [PubMed] [Google Scholar]
  31. Hamm C. W., Goldmann B. U., Heeschen C., Kreymann G., Berger J., Meinertz T. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med. 1997 Dec 4;337(23):1648–1653. doi: 10.1056/NEJM199712043372302. [DOI] [PubMed] [Google Scholar]
  32. Hamm C. W., Ravkilde J., Gerhardt W., Jørgensen P., Peheim E., Ljungdahl L., Goldmann B., Katus H. A. The prognostic value of serum troponin T in unstable angina. N Engl J Med. 1992 Jul 16;327(3):146–150. doi: 10.1056/NEJM199207163270302. [DOI] [PubMed] [Google Scholar]
  33. Hoffmeister H. M., Jur M., Wendel H. P., Heller W., Seipel L. Alterations of coagulation and fibrinolytic and kallikrein-kinin systems in the acute and postacute phases in patients with unstable angina pectoris. Circulation. 1995 May 15;91(10):2520–2527. doi: 10.1161/01.cir.91.10.2520. [DOI] [PubMed] [Google Scholar]
  34. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998 Aug 13;339(7):436–443. doi: 10.1056/NEJM199808133390704. [DOI] [PubMed] [Google Scholar]
  35. International, randomized, controlled trial of lamifiban (a platelet glycoprotein IIb/IIIa inhibitor), heparin, or both in unstable angina. The PARAGON Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network. Circulation. 1998 Jun 23;97(24):2386–2395. doi: 10.1161/01.cir.97.24.2386. [DOI] [PubMed] [Google Scholar]
  36. Jonasson L., Holm J., Skalli O., Bondjers G., Hansson G. K. Regional accumulations of T cells, macrophages, and smooth muscle cells in the human atherosclerotic plaque. Arteriosclerosis. 1986 Mar-Apr;6(2):131–138. doi: 10.1161/01.atv.6.2.131. [DOI] [PubMed] [Google Scholar]
  37. Kennon S., Price C. P., Mills P. G., Ranjadayalan K., Cooper J., Clarke H., Timmis A. D. The effect of aspirin on C-reactive protein as a marker of risk in unstable angina. J Am Coll Cardiol. 2001 Apr;37(5):1266–1270. doi: 10.1016/s0735-1097(01)01130-5. [DOI] [PubMed] [Google Scholar]
  38. Lindahl B., Andrén B., Ohlsson J., Venge P., Wallentin L. Risk stratification in unstable coronary artery disease. Additive value of troponin T determinations and pre-discharge exercise tests. FRISK Study Group. Eur Heart J. 1997 May;18(5):762–770. doi: 10.1093/oxfordjournals.eurheartj.a015341. [DOI] [PubMed] [Google Scholar]
  39. Lindahl B., Diderholm E., Lagerqvist B., Venge P., Wallentin L., FRISC II(Fast Revascularization during InStability in CAD) Investigators Mechanisms behind the prognostic value of troponin T in unstable coronary artery disease: a FRISC II substudy. J Am Coll Cardiol. 2001 Oct;38(4):979–986. doi: 10.1016/s0735-1097(01)01501-7. [DOI] [PubMed] [Google Scholar]
  40. Lindahl B., Venge P., Wallentin L. Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease. The FRISC study group. Circulation. 1996 May 1;93(9):1651–1657. doi: 10.1161/01.cir.93.9.1651. [DOI] [PubMed] [Google Scholar]
  41. Little W. C., Constantinescu M., Applegate R. J., Kutcher M. A., Burrows M. T., Kahl F. R., Santamore W. P. Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease? Circulation. 1988 Nov;78(5 Pt 1):1157–1166. doi: 10.1161/01.cir.78.5.1157. [DOI] [PubMed] [Google Scholar]
  42. Lüscher M. S., Thygesen K., Ravkilde J., Heickendorff L. Applicability of cardiac troponin T and I for early risk stratification in unstable coronary artery disease. TRIM Study Group. Thrombin Inhibition in Myocardial ischemia. Circulation. 1997 Oct 21;96(8):2578–2585. doi: 10.1161/01.cir.96.8.2578. [DOI] [PubMed] [Google Scholar]
  43. Merlini P. A., Bauer K. A., Oltrona L., Ardissino D., Cattaneo M., Belli C., Mannucci P. M., Rosenberg R. D. Persistent activation of coagulation mechanism in unstable angina and myocardial infarction. Circulation. 1994 Jul;90(1):61–68. doi: 10.1161/01.cir.90.1.61. [DOI] [PubMed] [Google Scholar]
  44. Moreno P. R., Bernardi V. H., López-Cuéllar J., Murcia A. M., Palacios I. F., Gold H. K., Mehran R., Sharma S. K., Nemerson Y., Fuster V. Macrophages, smooth muscle cells, and tissue factor in unstable angina. Implications for cell-mediated thrombogenicity in acute coronary syndromes. Circulation. 1996 Dec 15;94(12):3090–3097. doi: 10.1161/01.cir.94.12.3090. [DOI] [PubMed] [Google Scholar]
  45. Morrow D. A., Rifai N., Antman E. M., Weiner D. L., McCabe C. H., Cannon C. P., Braunwald E. C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudy. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol. 1998 Jun;31(7):1460–1465. doi: 10.1016/s0735-1097(98)00136-3. [DOI] [PubMed] [Google Scholar]
  46. Nyman I., Larsson H., Areskog M., Areskog N. H., Wallentin L. The predictive value of silent ischemia at an exercise test before discharge after an episode of unstable coronary artery disease. RISC Study Group. Am Heart J. 1992 Feb;123(2):324–331. doi: 10.1016/0002-8703(92)90642-9. [DOI] [PubMed] [Google Scholar]
  47. O'Brien K. D., Allen M. D., McDonald T. O., Chait A., Harlan J. M., Fishbein D., McCarty J., Ferguson M., Hudkins K., Benjamin C. D. Vascular cell adhesion molecule-1 is expressed in human coronary atherosclerotic plaques. Implications for the mode of progression of advanced coronary atherosclerosis. J Clin Invest. 1993 Aug;92(2):945–951. doi: 10.1172/JCI116670. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Ohman E. M., Armstrong P. W., Christenson R. H., Granger C. B., Katus H. A., Hamm C. W., O'Hanesian M. A., Wagner G. S., Kleiman N. S., Harrell F. E., Jr Cardiac troponin T levels for risk stratification in acute myocardial ischemia. GUSTO IIA Investigators. N Engl J Med. 1996 Oct 31;335(18):1333–1341. doi: 10.1056/NEJM199610313351801. [DOI] [PubMed] [Google Scholar]
  49. Olatidoye A. G., Wu A. H., Feng Y. J., Waters D. Prognostic role of troponin T versus troponin I in unstable angina pectoris for cardiac events with meta-analysis comparing published studies. Am J Cardiol. 1998 Jun 15;81(12):1405–1410. doi: 10.1016/s0002-9149(98)00200-8. [DOI] [PubMed] [Google Scholar]
  50. Oler A., Whooley M. A., Oler J., Grady D. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis. JAMA. 1996 Sep 11;276(10):811–815. [PubMed] [Google Scholar]
  51. Patel D. J., Knight C. J., Holdright D. R., Mulcahy D., Clarke D., Wright C., Purcell H., Fox K. M. Long-term prognosis in unstable angina. The importance of early risk stratification using continuous ST segment monitoring. Eur Heart J. 1998 Feb;19(2):240–249. doi: 10.1053/euhj.1997.0586. [DOI] [PubMed] [Google Scholar]
  52. Poston R. N., Haskard D. O., Coucher J. R., Gall N. P., Johnson-Tidey R. R. Expression of intercellular adhesion molecule-1 in atherosclerotic plaques. Am J Pathol. 1992 Mar;140(3):665–673. [PMC free article] [PubMed] [Google Scholar]
  53. Rebuzzi A. G., Quaranta G., Liuzzo G., Caligiuri G., Lanza G. A., Gallimore J. R., Grillo R. L., Cianflone D., Biasucci L. M., Maseri A. Incremental prognostic value of serum levels of troponin T and C-reactive protein on admission in patients with unstable angina pectoris. Am J Cardiol. 1998 Sep 15;82(6):715–719. doi: 10.1016/s0002-9149(98)00458-5. [DOI] [PubMed] [Google Scholar]
  54. Richardson P. D., Davies M. J., Born G. V. Influence of plaque configuration and stress distribution on fissuring of coronary atherosclerotic plaques. Lancet. 1989 Oct 21;2(8669):941–944. doi: 10.1016/s0140-6736(89)90953-7. [DOI] [PubMed] [Google Scholar]
  55. Ridker P. M., Buring J. E., Shih J., Matias M., Hennekens C. H. Prospective study of C-reactive protein and the risk of future cardiovascular events among apparently healthy women. Circulation. 1998 Aug 25;98(8):731–733. doi: 10.1161/01.cir.98.8.731. [DOI] [PubMed] [Google Scholar]
  56. Ridker P. M., Cushman M., Stampfer M. J., Tracy R. P., Hennekens C. H. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med. 1997 Apr 3;336(14):973–979. doi: 10.1056/NEJM199704033361401. [DOI] [PubMed] [Google Scholar]
  57. Ridker P. M., Rifai N., Pfeffer M. A., Sacks F., Braunwald E. Long-term effects of pravastatin on plasma concentration of C-reactive protein. The Cholesterol and Recurrent Events (CARE) Investigators. Circulation. 1999 Jul 20;100(3):230–235. doi: 10.1161/01.cir.100.3.230. [DOI] [PubMed] [Google Scholar]
  58. Ryan T. J., Anderson J. L., Antman E. M., Braniff B. A., Brooks N. H., Califf R. M., Hillis L. D., Hiratzka L. F., Rapaport E., Riegel B. J. ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation. 1996 Nov 1;94(9):2341–2350. doi: 10.1161/01.cir.94.9.2341. [DOI] [PubMed] [Google Scholar]
  59. Ryan T. J., Antman E. M., Brooks N. H., Califf R. M., Hillis L. D., Hiratzka L. F., Rapaport E., Riegel B., Russell R. O., Smith E. E., 3rd 1999 update: ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: Executive Summary and Recommendations: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation. 1999 Aug 31;100(9):1016–1030. doi: 10.1161/01.cir.100.9.1016. [DOI] [PubMed] [Google Scholar]
  60. Schoenhagen P., Ziada K. M., Kapadia S. R., Crowe T. D., Nissen S. E., Tuzcu E. M. Extent and direction of arterial remodeling in stable versus unstable coronary syndromes : an intravascular ultrasound study. Circulation. 2000 Feb 15;101(6):598–603. doi: 10.1161/01.cir.101.6.598. [DOI] [PubMed] [Google Scholar]
  61. Simoons M. L., GUSTO IV-ACS Investigators Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomised trial. Lancet. 2001 Jun 16;357(9272):1915–1924. doi: 10.1016/s0140-6736(00)05060-1. [DOI] [PubMed] [Google Scholar]
  62. Solomon D. H., Stone P. H., Glynn R. J., Ganz D. A., Gibson C. M., Tracy R., Avorn J. Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy. J Am Coll Cardiol. 2001 Oct;38(4):969–976. doi: 10.1016/s0735-1097(01)01503-0. [DOI] [PubMed] [Google Scholar]
  63. Stefanadis C., Diamantopoulos L., Vlachopoulos C., Tsiamis E., Dernellis J., Toutouzas K., Stefanadi E., Toutouzas P. Thermal heterogeneity within human atherosclerotic coronary arteries detected in vivo: A new method of detection by application of a special thermography catheter. Circulation. 1999 Apr 20;99(15):1965–1971. doi: 10.1161/01.cir.99.15.1965. [DOI] [PubMed] [Google Scholar]
  64. Säfström K., Lindahl B., Swahn E. Risk stratification in unstable coronary artery disease--exercise test and troponin T from a gender perspective. FRISC-Study Group. Fragmin during InStability in Coronary artery disease. J Am Coll Cardiol. 2000 Jun;35(7):1791–1800. doi: 10.1016/s0735-1097(00)00655-0. [DOI] [PubMed] [Google Scholar]
  65. Säfström K., Nielsen N. E., Björkholm A., Wiklund G., Swahn E. Unstable coronary artery disease in post-menopausal women. Identifying patients with significant coronary artery disease by basic clinical parameters and exercise test. IRIS Study Group. Eur Heart J. 1998 Jun;19(6):899–907. doi: 10.1053/euhj.1997.0867. [DOI] [PubMed] [Google Scholar]
  66. Vickers Mark A., Green Fiona R., Terry Catherine, Mayosi Bongani M., Julier Cecile, Lathrop Mark, Ratcliffe Peter J., Watkins Hugh C., Keavney Bernard. Genotype at a promoter polymorphism of the interleukin-6 gene is associated with baseline levels of plasma C-reactive protein. Cardiovasc Res. 2002 Mar;53(4):1029–1034. doi: 10.1016/s0008-6363(01)00534-x. [DOI] [PubMed] [Google Scholar]
  67. Waters D. D., Hsue P. Y. What is the role of intensive cholesterol lowering in the treatment of acute coronary syndromes? Am J Cardiol. 2001 Oct 11;88(7B):7J–16J. doi: 10.1016/s0002-9149(01)01921-x. [DOI] [PubMed] [Google Scholar]
  68. Weitz J. I. Low-molecular-weight heparins. N Engl J Med. 1997 Sep 4;337(10):688–698. doi: 10.1056/NEJM199709043371007. [DOI] [PubMed] [Google Scholar]
  69. Willerson J. T., Golino P., Eidt J., Campbell W. B., Buja L. M. Specific platelet mediators and unstable coronary artery lesions. Experimental evidence and potential clinical implications. Circulation. 1989 Jul;80(1):198–205. doi: 10.1161/01.cir.80.1.198. [DOI] [PubMed] [Google Scholar]
  70. Yusuf S., Sleight P., Pogue J., Bosch J., Davies R., Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20;342(3):145–153. doi: 10.1056/NEJM200001203420301. [DOI] [PubMed] [Google Scholar]
  71. Yusuf S., Zhao F., Mehta S. R., Chrolavicius S., Tognoni G., Fox K. K., Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001 Aug 16;345(7):494–502. doi: 10.1056/NEJMoa010746. [DOI] [PubMed] [Google Scholar]
  72. de Beer F. C., Hind C. R., Fox K. M., Allan R. M., Maseri A., Pepys M. B. Measurement of serum C-reactive protein concentration in myocardial ischaemia and infarction. Br Heart J. 1982 Mar;47(3):239–243. doi: 10.1136/hrt.47.3.239. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. de Winter R. J., Bholasingh R., Lijmer J. G., Koster R. W., Gorgels J. P., Schouten Y., Hoek F. J., Sanders G. T. Independent prognostic value of C-reactive protein and troponin I in patients with unstable angina or non-Q-wave myocardial infarction. Cardiovasc Res. 1999 Apr;42(1):240–245. doi: 10.1016/s0008-6363(99)00018-8. [DOI] [PubMed] [Google Scholar]
  74. van der Wal A. C., Becker A. E., van der Loos C. M., Das P. K. Site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the dominant plaque morphology. Circulation. 1994 Jan;89(1):36–44. doi: 10.1161/01.cir.89.1.36. [DOI] [PubMed] [Google Scholar]
  75. van der Wal A. C., Das P. K., Tigges A. J., Becker A. E. Adhesion molecules on the endothelium and mononuclear cells in human atherosclerotic lesions. Am J Pathol. 1992 Dec;141(6):1427–1433. [PMC free article] [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES