[Current indications of myocardial revascularization in unstable angina]

Myocardial revascularisation is now an integral part of the treatment of unstable angina. Trials comparing the efficacy of coronary surgery and medical therapy date back to the end of the 1970s. They showed a clear benefit of revascularisation on functional status but a less pronounced effect on survival. Thus, at 10 years, half of the patients in the Veterans Administration series initially treated medically, underwent surgery; however the initial therapeutic choice was not a significant prognostic factor except in patients with triple vessel disease and those with left ventricular dysfunction whose survival was better when treated surgically. In the last 10 years, coronary angioplasty has become increasingly important in the treatment of unstable angina. The short-term results are very encouraging although complications are more common during the phase of clinical instability than when symptoms have been managed. The addition of thrombolytics to the conventional heparin and aspirin treatment during angioplasty seems to be potentially harmful rather than beneficial. However, new antithrombotic agents (platelets antiaggregants such as antiglycoprotein IIB-IIIA antibodies or direct inhibitors of thrombin such as hirudin or hirulog) seem to decrease the risks of this procedure. At term, the results obtained after angioplasty for unstable angina are similar to those observed in stable angina: the risk of restenosis seems to be about the same and the prognosis depends mainly on left ventricular function. In practice, the choice of therapeutic strategy in unstable angina remains open: the TIMI IIIB trial reported similar results at 6 months whether patients were treated by immediate coronary angiography or whether a more conservative strategy was adopted; the duration of the initial hospital stay was however shorter and the need for rehospitalisation was less frequent in those undergoing immediate coronary angiography.