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. 2009 Feb 3;21(5):314–322. doi: 10.1002/clc.4960210504

Management Strategies for a Better Outcome in Unstable Coronary Artery Disease

R W F Campbell 1,✉, L Wallentin 2, F W A Verheugt 3, A G G Turpie 4, A Maseri 5, W Klein 6, J G F Cleland 7, C Bode 8, R Becker 9, J Anderson 10, M E Bertrand 11, C R Conti 12
PMCID: PMC6655264  PMID: 9595213

Abstract

Unstable coronary artery disease is a term encompassing both unstable angina and non‐Q‐wave (non‐ST‐segment elevation) myocardial infarction. Patients with these conditions are at risk of early progression to acute myocardial infarction and death. Thus, management of these conditions must aim to reduce long‐term mortality and morbidity. Risk stratification is crucial for the identification of patients whose risk of early progression is high; they may require coronary angiography and (if suitable) either percutaneous transluminal coronary angioplasty or coronary artery bypass surgery. No single variable can accurately predict risk, but considerable data are emerging to show that biochemical markers of myocardial injury, such as troponin‐T and troponin‐I, are valuable in combination with electrocardiographic findings and clinical features. Routine early invasive procedures (coronary angiography with or without revascularization) have not yet been shown to have any significant advantage over conservative regimens for the majority of patients. Antiplatelet, anticoagulant, and anti‐ischemic agents remain the mainstay of treatment in the acute phase. New agents, such as glycoprotein IIb/IIIa receptor inhibitors and low‐molecular‐weight heparins, as well as antithrombins and Factor Xa inhibitors add to the treatments currently available. Thrombolytic agents are contraindicated in the absence of ST‐segment elevation. After clinical stabilization, ongoing assessment should include exercise testing for all patients who are able; other imaging techniques should be used for patients unable to exercise. A profile indicating a high risk of future events is an indication for elective angiography and consideration for revascularization.

Keywords: unstable coronary artery disease, risk stratification, troponin‐T, revascularization, anticoagulant, heparin

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References

  • 1. Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J: Insights into the pathogenesis of acute ischemic syndromes. Circulation 1988; 77: 1213–1220 [DOI] [PubMed] [Google Scholar]
  • 2. Graves EJ: Detailed diagnoses and procedures. National Hospital Discharge Summary, 1990. National Center for Health Statistics. Vital Health Statistics 1992; 13: 113 (Table 4) [PubMed] [Google Scholar]
  • 3. Braunwald E, Jones RH, Mark DB, Daniel BM, Brown J, Brown L, Cheitlin MD, Concannon CA, Cowan M, Edwards C, Fuster V, Goldman L, Green LA, Grines CL, Lytle BW, McCauley KM, Mushlin AI, Rose GC, Smith EE, Swain JA, Topol EJ, Willerson JT: Diagnosing and managing unstable angina: Agency for Health Care Policy and Research. Circulation 1994; 91: 2520–2527 [DOI] [PubMed] [Google Scholar]
  • 4. The EPIC Investigators : Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high‐risk coronary angioplasty. N Engl J Med 1994; 330: 956–961 [DOI] [PubMed] [Google Scholar]
  • 5. Théroux P: The PRISM‐plus study. Data presented at the American College of Cardiology Congress, March 1997, Anaheim, California, USA
  • 6. The CAPTURE Investigators : Randomised placebo‐controlled trial of abciximab before and during coronary intervention in refractory angina: The CAPTURE study. Lancet 1997; 349: 1429–1434 [PubMed] [Google Scholar]
  • 7. White HD: The PRISM study. Data presented at the American College of Cardiology Congress, March 1997, Anaheim, California, USA
  • 8. FRISC Study Group : Low‐molecular‐weight heparin during instability in coronary artery disease. Lancet 1996; 347; 561–568 [PubMed] [Google Scholar]
  • 9. Klein W, Buchwald A, Hillis SE, Monrad S, Sanz G, Turpie AGG, van der Meer J, Olaisson E, Undeland S, Ludwig K: Comparison of low‐molecular weight heparin with unfractionated heparin acutely and with placebo for 6 weeks in the management of unstable coronary artery disease. Fragmin in unstable coronary artery disease study (FRIC). Circulation 1997; 96: 61–68 [DOI] [PubMed] [Google Scholar]
  • 10. Cohen M, Demers C, Gurfinkel EP, Turpie A, Fromell G, Langer A, Califf R, Fox, K , Premmereur J, Bigonzi F for the Efficacy and Safety of Subcutaneous Enoxaparin in Non‐Q‐Wave Coronary Events (ESSENCE) Study Group: A comparison of low‐molecular‐weight heparin with unfractionated heparin for unstable coronary artery disease. N Engl J Med 1997; 337: 447–452 [DOI] [PubMed] [Google Scholar]
  • 11. Alexander KP, Peterson ED, Hellkamp AS, Granger CB, Topol EJ, Califf RM, and the GUSTO IIb Investigators : Early catheterisation is standard therapy in unstable angina/NQWMI: Results from GUSTO IIb. Data presented at the American College of Cardiology Congress, March 1997, Anaheim, California, USA
  • 12. The TIMI IIIB Investigators : Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non‐Q‐wave myocardial infarction. Results of the TIMI IIIB trial. Circulation 1994; 89: 1545–1556 [DOI] [PubMed] [Google Scholar]
  • 13. VANQWISH (Veterans' Affairs Non‐Q‐Wave Infarction Strategies in Hospitals) : Data presented at the American College of Cardiology Annual Scientific Session, Anaheim, California, March 1997.
  • 14. Rahimtoola SH: Coronary by‐pass surgery for unstable angina. Circulation 1984; 69: 842–848 [DOI] [PubMed] [Google Scholar]
  • 15. Maseri A: Ischemic heart disease In A Rational Basis for Clinical Practice and Clinical Research, p. 237–301. New York: Churchill Livingstone, 1995. [Google Scholar]
  • 16. Merlini PA, Bauer KA, Oltrona L, Ardissimo D, Cattanneo M, Belli C, Mannucci PM, Rosenberg RD: Persistent activation of coagulation mechanism in unstable angina and myocardial infarction. Circulation 1994; 90: 61–68 [DOI] [PubMed] [Google Scholar]
  • 17. Hoffmeister HM, Jur M, Wendel HP, Heller W, Seipel L: Alterations of coagulation and fibrinolytic and kallikrein‐kinin systems in the acute and postacute phases in patients with unstable angina. Circulation 1994; 91: 2520–2527 [DOI] [PubMed] [Google Scholar]
  • 18. Maseri A: Ischemic heart disease In A Rational Basis for Clinical Practice and Clinical Research, vii–viii p. 303–322. New York: Churchill Livingstone, 1995. [Google Scholar]
  • 19. Becker RC, Cannon CP, Bovill EG, Tracy RP, Thompson B, Knatterud GL, Randall A, Braunwald E: Prognostic value of plasma fibrinogen concentrations in patients with unstable angina and non‐Q‐wave myocardial infarction (TIMI III trial). Am J Cardiol 1996; 78: 142–147 [DOI] [PubMed] [Google Scholar]
  • 20. Vahanian A, Granger CB, Califf RM, Topol EJ, and the GUSTO‐IIb Investigators : Outcomes in GUSTO‐IIb in patients with ST‐depression versus those with T‐wave inversion. Abstract no 760‐1, presented at the American College of Cardiology Congress, March 1997, Anaheim, California, USA
  • 21. Chung MK, Bosner MS, McKenzie JP, Shen J, Rich MW: Prognosis of patients ≥ 70 years of age with non‐Q acute myocardial infarction compared with younger patients with similar infarcts and with patients ≥70 years of age with Q‐wave acute myocardial infarction. Am J Cardiol 1995; 75: 18–22 [DOI] [PubMed] [Google Scholar]
  • 22. Cannon CP, Thompson B, McCabe CH, Mueller HS, Kirshenbaum JM, Herson S, Nasmith JB, Chaitman BR, Braunwald E: Predictors of non‐Q‐wave acute myocardial infarction in patients with acute ischemic syndromes: An analysis from the Thrombolysis in Myocardial Ischemia (TIMI) III trials. Am J Cardiol 1995; 75: 977–981 [DOI] [PubMed] [Google Scholar]
  • 23. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits D, Gerstenblith G: Silent ischemia predicts infarction and death during 2 year followup of unstable angina. J Am Coll Cardiol 1987; 10: 756–760 [DOI] [PubMed] [Google Scholar]
  • 24. Murphy JJ, Connell PA, Hampton JR: Predictors of risk in patients with unstable angina admitted to a district general hospital. Br Heart J 1992; 67: 395–401 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Théroux P, Ouimet H, McCans J, Latour JG, Joly P, Levy G, Pelletier E, Juneau M, Stasiak J, deGuise P: Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med 1988; 320: 1014–1015 [DOI] [PubMed] [Google Scholar]
  • 26. Bugiardini R, Borghi A, Pozzati A, Ruggeri A, Puddu P, Maseri A: Relation of severity of symptoms to transient myocardial ischemia and prognosis in unstable angina. J Am Coll Cardiol 1995; 25: 597–604 [DOI] [PubMed] [Google Scholar]
  • 27. Yusuf S, Pepine CJ, Garces C, Pouleur H, Salem D, Kostis J, Benedict C, Rousseau M, Bourassa M, Pitt B: Effect of enalapril on myocardial infarction and unstable angina in patients with low ejection fractions. Lancet 1992; 340: 1173–1178 [DOI] [PubMed] [Google Scholar]
  • 28. Ohman EM, Armstrong PW, Christenson RH, Granger CB, Katus HA, Hamm CW, O'Hanesian MA, Wagner GS, Kleiman NS, Harrell FE, Califf RM, Topol EJ: Cardiac troponin T levels for risk stratification in acute myocardial ischemia. N Engl J Med 1996; 335: 1333–1341 [DOI] [PubMed] [Google Scholar]
  • 29. Antman EM, Tanasijevic MJ, Thompson B, Schactman M, McCabe CH, Cannon CP, Fischer GA, Fung AY, Thompson C, Wybenga D, Braunwald E: Cardiac‐specific troponin 1 levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996; 335: 1342–1349 [DOI] [PubMed] [Google Scholar]
  • 30. Lee TH, Rouan GW, Weisberg MC, Brand DA, Cook EF, Acampora D, Goldman L, and the Chest Pain Study Group : Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 hours of hospitalization. Ann Intern Med 1987; 106: 181–186 [DOI] [PubMed] [Google Scholar]
  • 31. Galvani M, Ottani F, Puggioni R, Femini D, Nanni C, Baccos D, Destro A, Rusticall F, Eisenberg P: Value of a new bedside D‐dimer assay for early risk stratification of patients with acute coronary syndromes. Circulation 1996; 94 (suppl 1): 133 [Google Scholar]
  • 32. Sbarouni E, Bradshaw A, Andreotti F, Tuddenham E, Oakley CM, Cleland JGF: Relationship between hemostatic abnormalities and neuroendocrine activity in heart failure. Am Heart J 1994; 127: 607–612 [DOI] [PubMed] [Google Scholar]
  • 33. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH: Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med 1997; 336: 973–979 [DOI] [PubMed] [Google Scholar]
  • 34. The RISC group : Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. Lancet 1990; 336: 827–830 [PubMed] [Google Scholar]
  • 35. CAPRIE Steering Committee : A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329–1328 [DOI] [PubMed] [Google Scholar]
  • 36. Oler A, Whooley MA, Oler J, Grady D: Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta‐analysis. J Am Med Assoc 1996; 276: 811–815 [PubMed] [Google Scholar]
  • 37. Ryan TJ, Anderson JL, Antman EM, Braniff BA, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel BJ, Russel RO, Smith EE Jr, Weaver WD: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Management of Acute Myocardial infarction). J Am Coll Cardiol 1996; 28: 1328–1428 [DOI] [PubMed] [Google Scholar]
  • 38. Liuzzo G, Biasucci LM, Buffon A, Quaranta G, Caligiuri G, Monaco C, Grillo RL, Rebuzzi AG, Maseri A: Elevated C‐reactive protein at discharge and at three months after waning of symptoms in unstable angina is associated with recurrence of instability during 12 months follow‐up (abstr). J Am Coll Cardiol 1995; 25 (suppl): 250A–251A [Google Scholar]
  • 39. Théroux P, Waters D, Lam J, McCans J: Reactivation of unstable angina after the discontinuation of heparin. N Engl J Med 1992; 327: 192–194 [DOI] [PubMed] [Google Scholar]
  • 40. Lindahl B, Venge P, Wallentin L, and the FRISC Study Group : Troponin‐T identifies patients with unstable coronary artery disease who benefit from long term antithrombotic protection. J Am Coll Cardiol 1997; 29 (1): 43–48 [DOI] [PubMed] [Google Scholar]
  • 41. The HINT Research Group : Early treatment of unstable angina in the coronary care unit: A randomised, double‐blind, placebo controlled comparison of recurrent ischaemia in patients treated with nifedipine or metoprolol or both. Br Heart J 1986; 56: 400–413 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42. Hohnloser SH, Meinertz T, Klingenheben T, Sydow B, Just H: Usefulness of esmolol in unstable angina pectoris. Am J Cardiol 1991; 67: 1319–1323 [DOI] [PubMed] [Google Scholar]
  • 43. Gibson RS, Boden WE, Théroux P, Strauss HD, Pratt CM, Gheorghiade M, Capone RJ, Crawford MH, Schlant RC, Kleiger RE, Young PM, Schechtman K, Perryman B, Roberts R, and the Diltiazem Reinfarction Study Group : Diltiazem and reinfarction in patients with non‐Q‐wave myocardial infarction. Results of a double‐blind, randomized, multicenter trial. N Engl J Med 1986; 315: 423–429 [DOI] [PubMed] [Google Scholar]
  • 44. Pepine CJ: The role of calcium antagonists in ischaemic heart disease. Eur Heart J 1995; 16 (suppl H): 19–24 [DOI] [PubMed] [Google Scholar]
  • 45. Ambrose JA, Almeida OD, Sharma SK, Torre SR, Marmur JD, Israel DH, Ratner DE, Weiss MB, Hjemdahl‐Monsen CE, Myler RK, Moses J, Unterecker WJ, Grunwald AM, Garrett JS, Cowley MJ, Anwar A, Sobolski J: Adjunctive thrombolytic therapy during angioplasty for ischaemic rest angina: Results of the TAUSA trial. Circulation 1994; 90: 69–77 [DOI] [PubMed] [Google Scholar]
  • 46. Braunwald E, Muller JE, McCabe CH, Knatterud GL, Thompson B, Prior MJ, Terrin M, Canner M, Depkin J, Giro R, Kufera J, Monroe WL, Wilkins P, Solomon R, Colling C, Chaitman B, Shaw L, Wiens RD, Brown BG, for the TIMI Investigators : Early effects of tissue‐type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest: Results of the thrombolysis in myocardial ischemia (TIMI IIIA) trial. Circulation 1993: 87: 38–52 [DOI] [PubMed] [Google Scholar]
  • 47. Braunwald E, for the TIMI IIIB Investigators : Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non‐Q‐wave myocardial infarction. Results of TIMI III B trial (Thrombolysis in Myocardial Ischemia). Circulation 1994; 89: 1545–1556 [DOI] [PubMed] [Google Scholar]
  • 48. FTT Collaborative Group : Indications for fibrinolytic therapy in suspected acute myocardial infarction: Collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343; 311–322 [PubMed] [Google Scholar]
  • 49. Vaitkus PT, Laskey WK: Efficacy of adjunctive thrombolytic therapy in percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1994: 24: 1415–1423 [DOI] [PubMed] [Google Scholar]
  • 50. Chapekis AT, George BS, Candela RJ: Rapid thrombus dissolution by continuous infusion of urokinase through an intracoronary perfusion wire prior to and following PTCA: Results in native coronaries and patent saphenous vein grafts. Cath Cardiovasc Diagn 1991; 23: 89–92 [DOI] [PubMed] [Google Scholar]
  • 51. Muhlestein JB, Karagounis LA, Trehan S, Anderson JL: “Rescue” utilization of abciximab for the dissolution of coronary thrombus developing as a complication of coronary angioplasty. J Am Coll Cardiol 1997; 30: 1729–1734 [DOI] [PubMed] [Google Scholar]
  • 52. The EPILOG Investigators : Platelet glycoprotein IIb/IIIa receptor blockade and low‐dose heparin during percutaneous coronary revascularization. N Engl J Med 1997; 336: 1689–1696 [DOI] [PubMed] [Google Scholar]
  • 53. Gold HK, Garabedian HD, Dinsmore RE, Guerrero LJ, Cigarroa JE, Palacios IF, Leinbach RC: Restoration of coronary flow in myocardial infarction by intravenous chimeric 7E3 antibody without exogenous plasminogen activators. Observations in animals and humans. Circulation 1997; 95: 1755–1759 [DOI] [PubMed] [Google Scholar]
  • 54. Pederson TR, for the Scandinavian Simvastatin Study Group : Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383–1389 [PubMed] [Google Scholar]
  • 55. Lindahl B, Andren B, Ohlsson J, Venge P, Wallentin L, and the FRISC Study Group : Risk stratification in unstable coronary artery disease: Additive value of troponin‐T determinations and predischarge exercise tests. Eur Heart J 1997; 18: 762–770 [DOI] [PubMed] [Google Scholar]
  • 56. Swahn E, Areskog M, Wallentin L: Risk stratification by early exercise testing after an episode of unstable coronary artery disease—safety and diagnostic value. Eur Heart J 1986; 7: 594–601 [DOI] [PubMed] [Google Scholar]
  • 57. Williams MJ, Odabastian J, Lauer MS, Thomas JD, Marwick TH: Prognostic value of dobutamine echocardiography in patients with left ventricular dysfunction. J Am Coll Cardiol 1996; 27: 132–139 [DOI] [PubMed] [Google Scholar]
  • 58. Krumholz HM, Howes CJ, Murillo JE, Vaccarino LV, Radford MJ, Ellerbeck EF: Validation of a clinical prediction rule for left ventricular ejection fraction after myocardial infarction in patients ≥65 years old. Am J Cardiol 1997; 80: 11–15 [DOI] [PubMed] [Google Scholar]
  • 59. De Wood MA, Sifter WF, Simpson CS, Spores J, Eugster GS, Judge TP, Hinnen ML: Coronary arteriographic findings soon after non‐Q‐wave myocardial infarction. N Engl J Med 1986; 315: 417–423 [DOI] [PubMed] [Google Scholar]

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