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[Unstable angina: from physiopathology to therapeutics]
1Service de cardiologie, hôpital Beaujon, Clichy.
Insights
Unstable angina, a critical stage before heart attack, requires immediate care. Effective treatments include medications and procedures like angioplasty or bypass surgery for complex coronary lesions.
Area of Science:
- Cardiology
- Internal Medicine
Context:
- Unstable angina encompasses various syndromes like crescendo angina and resting angina, bridging stable angina and myocardial infarction.
- Coronary angioscopy reveals distinct mechanisms: plaque ulceration in accelerated effort angina and thrombosis in resting angina.
- Diagnosis is clinical, necessitating urgent coronary care unit admission due to high risk of myocardial infarction and sudden death.
Purpose:
- To outline the clinical presentation, diagnostic criteria, and management strategies for unstable angina.
- To differentiate underlying pathophysiological mechanisms based on coronary angioscopy findings.
- To review current and emerging therapeutic options, including medical, interventional, and surgical approaches.
Summary:
- Medical management involves triple anti-ischemic therapy, anticoagulants, and antiplatelets, proven to reduce refractory angina and myocardial infarction.
- Emergency coronary angiography is indicated for refractory cases, though often delayed for safety.
- Complex coronary lesions, including eccentric stenosis and thrombosis, are common; revascularization via angioplasty or bypass is considered.
Impact:
- Current treatments decrease refractory angina and myocardial infarction incidence.
- Revascularization strategies like angioplasty or bypass surgery are recommended for complex lesions.
- Ongoing research evaluates thrombolytic therapy and compares revascularization techniques for optimal patient outcomes.
Abstract:
Unstable angina is a term which encompasses several clinical syndromes (crescendo angina, angina de novo, resting angina, postinfarction angina), intermediary between stable angina and myocardial infarction. The results of coronary angioscopy have allowed differentiation of accelerated effort angina which seems related to ulceration of an atheromatous plaque from resting angina, more commonly associated with intraluminal thrombosis. The diagnosis of unstable angina is clinical and justifies immediate hospital admission to a coronary care unit because of the risk of myocardial infarction and/or sudden death. Medical management comprises triple anti-ischemic therapy (nitrate derivatives, betablockers, calcium antagonists), anticoagulants and platelet antiagregants. Randomised therapeutic trials versus placebo have shown that this treatment decreases the incidence of refractory angina and myocardial infarction. Several studies are under way to assess the role of thrombolytic therapy in unstable angina. When unstable angina is refractory to maximal medical therapy, emergency coronary angiography should be performed. However the outcome is usually favourable and coronary angiography can be performed several days after the acute event. The coronary lesion responsible for unstable angina is often "complex", an eccentric, irregular, severe stenosis or appearances of thrombosis. Whenever possible, depending on the coronary lesion, myocardial revascularisation by coronary angioplasty or aorto-coronary bypass should be proposed. Surgical treatment has been shown to be more effective (symptomatic relief, improved survival) than medical therapy in patients with triple vessel disease. However, the results of studies comparing medical or surgical treatment with coronary angioplasty are not yet available.