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[Treatment of unstable angina]
1Service des maladies cardiovasculaires, Hôpital Cochin, Paris.
Insights
Early treatment of unstable angina with anti-thrombotic and anti-ischemic therapies effectively prevents myocardial infarction in over 90% of patients. Persistent ischemia may necessitate urgent angiography and revascularization.
Area of Science:
- Cardiology
- Internal Medicine
- Pharmacology
Context:
- Unstable angina requires prompt intervention to prevent progression to myocardial infarction.
- Coronary care units are crucial settings for initiating timely treatment.
Purpose:
- To outline the optimal medical management of unstable angina.
- To define criteria for escalation to invasive procedures like coronary angiography and revascularization.
Summary:
- Effective unstable angina treatment combines anti-thrombotic (aspirin, heparin) and anti-ischemic (beta-blockers, nitrates, calcium antagonists) therapies.
- Initial medical management is typically assessed over 12 hours.
- Persistent or recurrent ischemia despite optimal medical therapy warrants urgent coronary angiography and potential revascularization.
Impact:
- Early and adequate treatment significantly reduces the risk of myocardial infarction.
- Coronary angiography identifies high-risk patients (e.g., left main disease) who may benefit from bypass grafting.
- Revascularization is reserved for cases with recurrent ischemia refractory to medical management.
Abstract:
Adequate treatment of unstable angina, initiated soon enough in the setting of a coronary care unit, avoids evolution towards myocardial infarction in more than 90% of the patients. Treatment consists of a combination of anti-thrombotic and anti-ischemic therapies. Oral beta-adrenergic blockers and intravenous nitrates represent the usual anti-ischemic treatment; calcium antagonists will be prescribed as an adjunct therapy if the response is insufficient or if a vasospastic mechanism is suspected. Anti-thrombotic treatment usually consists of a combination of low dose aspirin and intravenous heparin. Twelve hours are usually sufficient to titrate this medical regimen and to assess its efficacy; if myocardial ischaemia persists or recurs despite this therapy, urgent coronary angiography and subsequent revascularization are warranted. Usually ischaemia is adequately controlled by medical therapy, elective coronary angiography is nevertheless useful to screen high risk patients (left main and severe three-vessel disease) needing coronary artery bypass graft. In most cases however revascularization, by surgery or angioplasty, will be considered only if ischaemia at rest or induced by exercise, recurs despite optimal medical treatment.