Targeting Therapy in Unstable Angina

Patients presenting to hospital with unstable angina should be risk profiled on admission and categorized as low, intermediate or high risk based on demographics, the presence and duration of ischemia, electrocardiographic changes and biochemical markers such as troponins T and I. Patients categorized as low risk can be assessed as outpatients for confirmation of the diagnosis, institution of therapy, non-invasiveive testing for inducible ischemia, and modification of risk factors. Patients categorized as intermediate risk should be admitted and treated with antithrombotic therapy and glycoprotein IIb/IIIa receptor antagonists while undergoing careful monitoring for ischemia. If any high-risk features occur during this period, the patient should be recategorized as high risk. Alternatively, if the symptoms and signs of ischemia settle, they can be recategorized as low risk and undergo noninvasiveive testing before discharge. Patients categorized as high risk should be treated with antithrombotic therapy and IIb/IIIa receptor antagonists with a plan to perform expeditious angiography and revascularization (if appropriate) before early discharge. Further studies are required comparing this approach in high-risk patients with one of IIb/IIIa receptor antagonist therapy without revascularization. The increased risk of cardiac events continues beyond the acute phase, and long-term strategies, including administration of either low molecular weight heparin or oral IIb/IIIa receptor antagonists, are being tested in ongoing clinical trials.