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[Present views on unstable forms of ischemic coronary disease]
1II. interní klinika 1., lékarské fakulty UK, Praha.
Insights
Unstable angina pectoris is better termed unstable myocardial ischemia or unstable coronary syndromes due to varied causes. Plaque instability, thrombosis, and spasm are key factors in these serious heart conditions.
Area of Science:
- Cardiology
- Cardiovascular Medicine
- Pathophysiology
Background:
- Unstable angina pectoris encompasses diverse ischemic heart disease forms with varied pathophysiology and prognosis.
- Understanding plaque nature is crucial for diagnosing unstable myocardial ischemia.
- Existing terminology may not fully capture the complexity of these conditions.
Purpose of the Study:
- To clarify the pathophysiology of unstable myocardial ischemia.
- To evaluate the suitability of current terminology for unstable coronary syndromes.
- To correlate plaque characteristics with clinical presentation and outcomes.
Main Methods:
- Review of angiographic, angioscopic, and autoptic observations.
- Holter ECG monitoring in patients with unstable angina pectoris.
- Analysis of coronary angiography findings.
Main Results:
- Coronary angiography revealed eccentric narrowing and intraluminal defects in 71-73% of affected vessels.
- Autoptic studies indicated thrombus formation on fissured, ulcerated, or hemorrhaged plaques.
- Impaired plaque integrity, platelet activation, thrombosis, and coronary spasm are common pathways.
Conclusions:
- The term unstable myocardial ischemia or unstable coronary syndromes is more appropriate than unstable angina pectoris.
- Plaque instability is the central mechanism driving these syndromes.
- Despite medical or surgical interventions, risks of myocardial infarction and sudden death persist.
Abstract:
The term unstable angina pectoris covers several forms of ischemic heart disease with heterogeneous pathophysiology, different clinical presentation and non-uniform prognosis. Recent results of angiographic, angioscopic and autoptic observations on the nature of unstable coronary plaque rendered possible a better understanding of clinical symptoms of the unstable myocardial ischemia. Holter ECG monitoring of patients with unstable angina pectoris showed, that myocardial ischemia may persist despite the medical control of angina pectoris. It seems therefore more appropriate to use the terms unstable myocardial ischemia or unstable coronary syndromes rather than unstable angina pectoris. Coronary angiography in patients with unstable angina pectoris demonstrated eccentric narrowing with irregular or overhanging edges or intraluminal filling defects in 71-73% of vessels responsible for unstable myocardial ischemia. Autoptic studies showed, that thrombus usually develops on plaque with fissures, ulcerations and hemorrhage. The common pathway for all unstable coronary syndromes is an impairment of plaque integrity with subsequent activation of platelets, development of thrombosis and coronary spasm. Subsequent fate of coronary thrombus determines the clinical course with ischemic episodes lasting from several minutes to several hours. Medical therapy, PTCA or coronary bypass surgery are used to stabilise the patient, however, myocardial infarction or sudden death may occur.