New approaches to diagnosis and management of unstable angina and non-ST-segment elevation myocardial infarction
R A O'Rourke1, J S Hochman, M C Cohen
1Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78284, USA.
Insights
New antiplatelet and antithrombin drugs improve outcomes for patients with unstable angina or non-ST-segment elevation myocardial infarction (MI). This review details clinical studies and treatment algorithms for these high-risk cardiovascular conditions.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Non-Q-wave myocardial infarction (MI) and unstable angina pectoris share clinical features and initial management strategies.
- High-risk patients with these conditions benefit from advanced antiplatelet and antithrombin therapies.
Purpose of the Study:
- To review clinical studies on glycoprotein IIb-IIIa inhibitors and low-molecular-weight heparin for unstable angina/non-ST-segment elevation MI.
- To present findings from key trials comparing conservative versus aggressive treatment approaches.
Main Methods:
- Review of clinical trials including Thrombolysis in Myocardial Infarction IIIB, VA Non-Q-Wave Infarction Studies, and FRISC II.
- Evaluation of glycoprotein IIb-IIIa inhibitors (tirofiban, eptifibatide) with unfractionated or low-molecular-weight heparin (enoxaparin).
Main Results:
- Glycoprotein IIb-IIIa inhibitors and low-molecular-weight heparin demonstrate efficacy in managing high-risk unstable angina/non-ST-segment elevation MI.
- Comparative studies highlight the effectiveness of different treatment strategies.
Conclusions:
- Current evidence supports the use of novel antiplatelet and antithrombin agents in specific patient populations.
- A practical treatment algorithm is proposed for guiding clinical decisions in unstable angina/non-ST-segment elevation MI.
Abstract:
Recently, it has been demonstrated in multiple clinical research studies that non-Q-wave myocardial infarction shares many of the features of unstable angina pectoris and that both diseases initially are managed similarly. Important new antiplatelet drugs (glycoprotein IIb-IIIa inhibitors) and antithrombin agents (low-molecular-weight heparin) are currently recommended for patients with unstable angina pectoris/non-ST-segment elevation MI who are at high or intermediate risk on the basis of symptoms, electrocardiographic findings, and the presence or absence of serum markers (eg, troponin I, troponin T, and creatine kinase-MB). This review provides important information concerning the results of clinical studies of glycoprotein IIb-IIIa inhibitors (tirofiban hydrochloride and eptifibatide) when used with unfractionated heparin in patients with this syndrome or with low-molecular weight heparin (enoxaparin sodium) in similar patients. The Thrombolysis in Myocardial Infarction IIIB, Veterans Affairs Non-Q-Wave Infarction Studies in Hospital, and Fast Revascularization During Instability in Coronary Artery Disease II studies evaluating a conservative, ischemia-guided approach vs an early aggressive approach to such patients are presented, with a practical algorithm for treating such patients.
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