The importance of pre- and postinfarction angina on timolol-related reduction in mortality and reinfarction

The importance of a history of angina pectoris on long-term timolol treatment after myocardial infarction was studied with respect to mortality and reinfarction. The analyses were performed retrospectively using cohorts from the Norwegian timolol multicenter study. In patients without angina pectoris prior to the infarction, timolol treatment reduced mortality by 61% and the occurrence of first nonfatal reinfarction by 16.9% as compared with placebo. Patients with preinfarction angina had a reduction in mortality of 21.8% and in first nonfatal reinfarction of 48.6%. The frequency of angina pectoris increased from 38% in both treatment groups before the infarction to 59% in the placebo group and 52% in the timolol group the first 6 months after the infarction. In patients without postinfarction angina pectoris, timolol treatment reduced mortality by 30.7% and the number of first nonfatal reinfarctions by 22.7%. The reductions in mortality and reinfarction in patients with postinfarction angina were 43.8% and 38.5%, respectively. Thus, the decision for timolol treatment after myocardial infarction should not be dependent on pre- and postinfarction angina.     

Clinical evidence suggesting vasospastic cause of myocardial infarction

To examine the vasospastic cause of myocardial infarction (MI) we studied 1) the incidence of rest angina before MI, 2) clinical features of postinfarction angina and 3) the occurrence of MI in variant angina. 1) Of 178 patients with MI, 60 (34%) experienced rest angina for 1 day to 10 years before the onset of MI. The incidence of rest angina was significantly higher in patients having milder coronary stenosis of 75% or less (15/30, 50%) than in others having severe stenosis of 90% or more (45/148, 30%), p less than 0.05. 2) Postinfarction angina with ST elevation was observed in 16 patients (9%) and ST elevation developed in leads with pathological Q waves in all patients. The incidence of postinfarction angina was significantly higher in those having milder coronary stenosis than in others having severe stenosis, (27% versus 5%, p less than 0.005). Patients with postinfarction angina experienced rest angina before MI more frequently (81%) than others (29%, p less than 0.005). Sublingual nitroglycerin was effective in relieving postinfarction angina attacks and oral calcium antagonist prevented attacks in all patients. 3) MI developed in 9 of 97 patients with variant angina. Six patients had transmural and 3, non-transmural MI. Pathological Q waves and/or coronary T waves appeared in leads where ST elevation was observed during anginal attack. In 7 patients MI developed when antispastic agents were not used and in 2, when angina persisted even under treatment with calcium antagonist. These data strongly suggest that the coronary spasm can be a cause of MI in some patients.     

Adaptive remodeling of the infarct-related artery is associated with recurrent ischemic events after thrombolysis in acute myocardial infarction

BACKGROUND: Recurrent ischemic events occur during the hospital stay of 7-32% of patients after successful thrombolytic treatment of acute myocardial infarction (AMI). OBJECTIVE: To define the association between postinfarction angina pectoris and the clinical, angiographic, and intravascular ultrasound (IVUS) parameters of the infarct-related artery for consecutive prospectively included patients. METHODS: Clinical, qualitative, and quantitative angiographic and IVUS data for 64 patients (56 men, aged 53+/-12 years) with thrombolysis of AMI were analyzed. All patients underwent coronary angiography and pre-interventional IVUS measurement electively within 1 month of AMI or at the time of the occurrence of postinfarction angina pectoris. Classification as adaptive or constrictive remodeling was according to whether the cross-sectional area of a vessel was larger or smaller than that of the proximal or distal reference segment. RESULTS: Nineteen of the 64 patients (29.7%) suffered from recurrence of ischemic events (group 1), whereas 45 patients (60.3%, group 2) remained free from symptoms. In univariate analyses, multivessel disease (42 versus 24%, P= 0.0236) and adaptive remodeling (63 versus 24%, P= 0.0032) were found to occur more commonly among patients in group 1. The patients in group 1 exhibited larger total vessel cross-sectional areas than did the patients in group 2 (17.5+/-4.2 versus 14.9+/-6.1 mm2, P = 0.0556). In multivariate regression analysis, adaptive remodeling proved to be a significant predictor (P = 0.0145) of the recurrence of ischemic events after thrombolysis of AMI. CONCLUSIONS: Adaptive remodeling of the infarct-related artery is associated with early postinfarction angina pectoris after thrombolysis of AMI.     

美托洛尔治疗急性心肌梗死的疗效及安全性

目的探讨静注及口服美托洛尔对急性心肌梗死（AM I）患者安全性及临床疗效。方法365例发病在24 h内的AM I患者随机分成美托洛尔治疗组（n=182例）和对照组（n=183例）,在常规治疗的基础上,治疗组给予静注及口服美托洛尔,对照组给予安慰剂,观察两组患者临床特征,住院期间治疗前后平均血压、心率及主要心脏不良事件发生情况。结果美托洛尔组患者吸烟和饮酒患者的比例显著高于对照组（P<0.05）,其他一般临床特征相同;美托洛尔组患者用药前后血压及心率下降幅度与对照组相比均存在显著性差异（P<0.05）;美托洛尔组患者发生梗死后心绞痛和室性心律失常的比率显著少于对照组（P<0.05）,发生再梗、脑梗、心源性休克和住院期间死亡的比率,与对照组相比无统计学差异。结论早期静注及口服美托洛尔,可明显降低AM I患者室性心律失常和梗死后心绞痛发生率,但并不降低住院期间总的病死率。     

Extracardiac contributions to chest pain perception in patients 6 months after acute myocardial infarction

OBJECTIVES: The amount of perceived anginal pain in patients after infarction deserves the attention of the physician. This study sought to identify the modulating influence of extracardiac factors on persistent angina pectoris after myocardial infarction. METHODS AND RESULTS: A total of 552 male survivors of acute myocardial infarction (age 29 to 65 years, median 54 years) were followed for a period of 6 months; the affective state was assessed immediately after the acute event. The prognostic importance of postinfarction depression on chest pain perception was evaluated 6 months after the cardiac event in 376 patients. After the 6-month follow-up period, 199 (53%) of the patients with myocardial infarction had angina pectoris. Somatic risk factors and electrocardiographic data at initial testing did not contribute to the risk of having chest pain. However, patients with high levels of depression at initial testing had an almost 3-fold risk of having angina pectoris 6 months after the index event. Older age, lower social class status, and preinfarction angina were also significantly related to angina pectoris at the end of the study. Patients who were pain free before the index infarction reported significantly more symptoms of chest pain at the study end point (P 相似文献   

Appearance of T-wave inversions without raised serum enzyme activity in suspected acute myocardial infarction: clinical outcome in relation to subendocardial infarction

In 67 patients with a clinical history of suspected acute myocardial infarction (MI) who developed T-wave inversions in standard ECG and had normal serum aspartate aminotransferase activity (possible MI) the clinical outcome was compared with that in patients fulfilling criteria for subendocardial infarction. Patients with possible MI had a lower mortality (p = 0.02) and also a lower reinfarction rate (p = 0.14) during the first 2 years as compared with those with subendocardial MI. Although patients with subendocardial MI had more problems with chest pain in the acute phase, angina pectoris occurred more frequently in patients with possible MI during a longer follow-up period. Congestive heart failure occurred more frequently in patients with subendocardial MI during initial hospitalization, whereas treatment for heart failure appeared similar in the two groups during a longer follow-up time. We conclude that the clinical course in patients with possible MI, here defined as chest pain and appearance of T-wave inversions without elevation of serum enzyme activity, seems to differ from that in patients with subendocardial MI, particularly regarding long-term survival and incidence of angina pectoris.     

Asymptomatic myocardial ischemia

Silent (asymptomatic) myocardial ischemia (SMI) is defined as a transient alteration in myocardial perfusion in the absence of chest pain or the usual anginal equivalents. Patients may be classified as having one of the three types of SMI: type A--totally asymptomatic patients with no history of angina or myocardial infarction; type B--asymptomatic patients with previous myocardial infarction; type C--patients with angina and asymptomatic ischemic episodes. SMI has been found in 2.5% of all healthy males aged 40-59 and in 20% of all postinfarction patients. In type C-patients, 80% has been found to have asymptomatic ischemic episodes in addition to typical angina pectoris. The frequency of SMI may be up to three or four times that of anginal attacks. SMI patients have generally reduced sensitivity to pain an differences in severity an duration of ischemic episodes. Diagnosis is based on screening by means of exercise testing in patients working in specific professions (like pilots, busdrivers etc.), in postinfarction patients and in patients after unstable angina pectoris and after coronary bypass surgery or coronary angioplasty. Prognosis is the same as in asymptomatic ischemia. SMI is an indicator of instability in certain groups of patients (post infarction, after unstable angina pectoris). SMI persisting after medical therapy of unstable angina is associated with adverse short-term-prognosis, therefore coronary surgery or angioplasty is indicated.     

Efficacy of fenigidin, senzit and trazikor in the treatment of patients with angina pectoris

One hundred patients with angina pectoris were studied to determine the antianginal effectiveness of senzit, fenigidin and trasicor. The calcium antagonists senzit and fenigidin were found to have high antianginal effect (44% and 78%, respectively) in patients with stable angina pectoris. It was found advisable to use the two drugs in combination with cardiac glycosides in patients with heart failure. A study showed the high antianginal effect of trasicor in postinfarction patients with refractory angina of effort.     

Aortocoronary shunting in the early period after myocardial infarction

Fourteen patients aged 34-54 years underwent aortocoronary bypass surgery for early postinfarction angina within 30 days following myocardial infarction. In periods up to 1.5 years after surgery, angina pectoris was not detected in the patients; cases of recurrent myocardial infarction were not registered.     

Predicting the efficacy of rehabilitation in patients with prior myocardial infarction]

The results of a 2-year follow-up of 400 patients with prior myocardial infarction (MI) and bicycle ergometric findings of intracardiac hemodynamic parameters and oxygen supply during exercise tests, and the criteria for tetrachoric index significance within the confidence intervals were used to reveal the factors predicting the efficacy of rehabilitative treatment. To predict decreased working capacity in the long-term period is determined by the extent of lesion after myocardial reinfarction, while angina pectoris and arterial hypertension are of significance in patients without reinfarction. A role of dynamic indices was defined in predicting decreased working capacity. Further lowered working capacity may be judged from the changes occurring in threshold exercise capacity and left ventricular end-diastolic volume in the first 6 months of postinfarction.     

Prognostic value of submaximal exercise radionuclide ventriculography after myocardial infarction

Submaximal exercise testing with radionuclide ventriculography (RVG) was performed in 117 patients before hospital discharge 17 +/- 7 days (+/- standard deviation) after an acute myocardial infarction (MI). The hypothesis tested in these studies was that submaximal exercise testing coupled to RVG allows the identification of patients at risk for future ischemic events in the subsequent 6 months, irrespective of MI location and type. The sites of MI were characterized as anterior transmural in 33, inferior transmural in 39, limited nontransmural in 18, extensive nontransmural in 24 and indeterminant in 3. During 6 months of follow-up, 9 patients died, 14 had recurrent MI, 18 had refractory angina pectoris, 16 had limiting angina and 17 had congestive heart failure. Discriminant function analysis ranked exercise changes in left ventricular (LV) ejection fraction and end-systolic volume the most important of all clinical, exercise and scintigraphic variables for predicting future cardiac events. The predictive accuracy of changes in LV ejection fraction and end-systolic volume were 93 and 91%, respectively, for the entire group, and were significantly more sensitive than any degree of ST-segment depression or elevation (p less than 0.001). These findings were generally independent of MI location and type. Thus, submaximal exercise RVG after MI is an accurate means of identifying patients at risk for major cardiac events in the 6 months after hospital discharge.     

Evaluation of clinical factors involved in onset of myocardial infarction

In order to discuss the mechanism of onset in myocardial infarction (MI), clinical cases were reviewed and various clinical findings were analyzed according to the premise that the onset of MI requires both a predisposition and a trigger. The majority of subjects did present conditions that constituted predispositions for MI, including a history of angina pectoris (especially unstable angina), poor therapeutic results for angina pectoris, organic stenosis of the coronary artery, life changes, and overwork. Patients with multiple factors tended to develop MI without a definite trigger, i.e., onset during sleep or rest whereas, in patients with fewer predisposing factors, it was obvious effort, excitation or stress that triggered MI. However, not a few of the patients presented with no organic stenosis of the coronary artery or no history of angina pectoris. There were patients without ST segment elevation at onset of MI, and patients in whom ST elevation was recorded after onset. These findings suggest the existence of mechanisms other than coronary occlusion in onset of MI. Occlusion of the coronary artery distributed to the infarct region occurred frequently among patients with delayed CPK efflux as well as prolonged chest pain and ST segment elevation. These lines of evidence suggest extension of infarction due to secondary coronary occlusion.     

Myocardial infarction in young adults under 30 years: risk factors and clinical course

The clinical features and course of 30 patients (26 men and 4 women) under 30 years of age (mean age 27.3 years) with an acute myocardial infarction (MI) are described. The most common risk factor among this group of patients was smoking in 20 patients (66%). The prevalence of the other risk factors was low: hyperlipidemia in four patients and family history of ischemic disease in another four patients, diabetes mellitus, hypertension, and obesity each in one patient. Seven patients (23%) had none of the conventional risk factors. Three patients were exerting themselves prior to the onset of their MI pain; all of them had normal coronaries. Five patients experienced chest pain prior to MI, among them only two experienced classical angina pectoris. Eighteen patients underwent uncomplicated MI. The complications in the other 12 during the acute MI were rhythm disturbances in eight and congestive heart failure in four. Cardiac catheterization was performed in 25 patients. The occurrence of zero, one, or multivessel disease was equal. The 30 patients were followed up from six months to 15 years (mean 7 years). In 18 patients circulating aggregated platelets were measured one year after the MI. Elevated values were found in all of them (mean +/- SD 34.9 +/- 9.1%). In 6 of the 18, all heavy smokers, extreme values were found in the range of 39-55%. Three out of the 30 patients died within five years after their first MI. The other 15 patients developed complications, most of them angina pectoris. Five patients were hospitalized for reinfarction. None of the 30 underwent aortocoronary bypass operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is preinfarction angina associated with better outcome after myocardial infarction?

BACKGROUND. In a clinical setting of acute myocardial infarction (MI), short-lasting and transient anginal pain, preceding the development of acute MI, is regarded as a symptom representing ischaemic preconditioning. Some experimental and clinical data suggested that preinfarction angina may favourably influence the course of acute MI. AIM. We sought to examine the hypothesis that preinfarction angina occurring within 24 hours prior to the onset of acute MI favourably influences the outcome. METHODS. The study group consisted of 331 patients who were admitted to our hospital due to acute MI with ST segment elevation with a symptom duration <12 hours and received thrombolysis. Preinfarction angina within 24 hours prior to MI was present in 80 patients whereas the remaining 251 patients had no chest pain preceding acute MI. The course of the in-hospital phase of MI (mean 15 days) was analysed. RESULTS. In patients with preinfarction angina the in-hospital complication rate was significantly lower than in patients without angina preceding acute MI (p<0.001). Patients without preinfarction angina more frequently developed heart failure (p<0.001) or died (p<0.01) in hospital. Patients with preinfarction angina had significantly less extensive MI and had reperfusion symptoms more frequently. Multivariate analysis showed that there were three factors which independently favourably influenced survival: preinfarction angina (p=0.01), age < or =65 years (p=0.04) and duration of chest pain during acute MI < or =3h (p=0.03). Of the analysed group, 73 patients died in hospital. The independent variables predicting death included prior MI (p=0.04), history of diabetes (p=0.02), acute left bundle branch block (p=0.01) and age >65 years (p=0.03). Non-fatal re-infarction complicated the in-hospital course of MI in 27 patients. The independent variables which predicted this complication included age >65 years (p=0.03) and hypercholesterolemia (p=0.04). CONCLUSIONS. Patients with preinfarction angina, occurring within 24 hours of acute MI, have better in-hospital outcome and less extensive myocardial injury than patients without antecedent angina. These results may be attributed to the protective effects of ischaemic preconditioning.     

Time course of endothelin-1 plasma level in patients with acute coronary syndromes.

An elevated plasma level of endothelin-1 was reported in several cardiovascular conditions including unstable angina pectoris and myocardial infarction. The present study was designed to evaluate the time course of the endothelin-1 release in unstable angina pectoris and to assess its relationship to the development of myocardial infarction and coronary vessel occlusion. The cohort studied included 32 patients with the clinical diagnosis of unstable angina pectoris who had been admitted to the coronary care unit and subsequently underwent coronary angiography (group A). Fourteen patients with chronic stable angina pectoris referred to routine diagnostic coronary angiography served as the control group (group B). A significant difference in the endothelin-1 plasma level was found between both groups, the values being 10.2 +/- 5.3 and 6.0 +/- 3.1 pg/ml (p < 0.01), respectively. There were, however, no significant differences between the following subdivisions of group A: patients with and without subsequent myocardial infarction; those with angiographically documented occlusion of at least one major branch of the coronary artery and no occlusion; and finally, those with persisting symptoms of angina pectoris and with favorable response to treatment. Neither was there any difference found among the subgroups differing in the time interval between the onset of chest pain and blood sampling. The time course of endothelin plasma concentrations showed elevated values lasting for more than 96 h after the index episode of prolonged chest pain. No correlation with the subsequent clinical course could be inferred. Thus, plasma endothelin level was elevated in patients with unstable angina pectoris and myocardial infarction and the increase persisted for several days after the onset of symptoms.     

Prognostic implications of renal dysfunction in patients with stable angina pectoris

OBJECTIVE: Impaired renal function is emerging as an independent risk factor for cardiovascular (CV) disease. We analysed the prognostic implications of estimated renal function in patients with angina pectoris. DESIGN: Post hoc analysis of the Angina Prognosis Study In Stockholm (APSIS). The estimated creatinine clearance (eCrCl) was calculated according to the Cockcroft-Gault formula in 808 patients. Outcomes were compared for subgroups with CrCl > or =90, 60-89 and<60 mL min(-1). Setting. Hospital-based study with patients referred from primary care and hospital. SUBJECTS: A total of 809 patients (248 women) with clinically diagnosed stable angina pectoris. Intervention. Double-blind treatment with metoprolol or verapamil. RESULTS: One hundred and sixty-four patients (91 women) had an eCrCl below 60 mL min(-1). During a median follow-up of 40 months, 38 patients suffered CV death and 31 patients had a nonfatal myocardial infarction (MI). In a univariate analysis a lower eCrCl was related to a higher risk for CV death or MI amongst men (log rank P = 0.036). A multivariate Cox analysis showed an independent prognostic importance of eCrCl for CV death (P = 0.046) and for CV death or MI (P = 0.042) amongst all patients. When analysed as a continuous variable, a 1 mL min(-1) decrease in eCrCl was associated with a 1.6% (0.1-3.1) increase in the risk for CV death or MI, and a 2.1% (0-4.1) increase in the risk for CV death alone. CONCLUSION: Renal dysfunction was found to be common in patients with stable angina pectoris and estimated creatinine clearances carried significant independent prognostic information regarding CV death and nonfatal MI.     

氯吡格雷对ST段抬高型急性心肌梗死的长期疗效观察

目的:观察溶栓治疗基础上联合氯吡格雷治疗ST段抬高型急性心肌梗死(STEAMI)的长期疗效及安全性.方法:将100例72 h以内发病的未行冠状动脉介入治疗的STEAMI患者随机均分为2组.A组行标准治疗(即静脉溶栓、抗凝、降脂、减轻心脏氧耗等),B组患者在A组治疗基础上入院即刻给予氯吡格雷300 mg口服,继之75 mg/d,治疗1年.观察梗死后心绞痛发作及死亡、再发心肌梗死或脑卒中的联合终点.结果:与A组相比,B组患者梗死后心绞痛发作明显减少,死亡、再发心肌梗死或脑卒中的联合终点也有显著下降,2组比较差异有统计学意义,P<0.05;2组均无主要和次要出血事件发生,轻微出血发生率2组比较差异无统计学意义(P>0.05).结论:STEAMI患者在溶栓治疗的基础上早期加用氯吡格雷300 mg负荷量,继之75 mg/d口服,治疗1年,可显著降低梗死后心绞痛的发作及死亡、再发心肌梗死或脑卒中的联合终点,且安全耐受性好.     

Excess triiodothyronine as a risk factor of coronary events

BACKGROUND: Abnormalities in cardiac function, eg, arrhythmias and congestive heart failure, often accompany thyrotoxicosis. A relationship between thyroid hormone excess and the cardiac complications of angina pectoris and myocardial infarction (MI) remains largely speculative. METHODS: The results of thyroid function studies on blood samples drawn from a total of 1049 patients (aged 40 years or older) immediately on emergency medical admission were related to frequencies of angina pectoris and myocardial infarction as determined according to current diagnostic algorithms. After 3 years, those patients who had initially presented with angina pectoris or acute MI were observed for subsequent coronary events; of these (n=185), 98% of the subjects (n=181) could be reevaluated. RESULTS: On hospital admission, the relative rate of angina pectoris and MI was markedly high (odds ratio, 2.6; 95% confidence interval, 1.3-5.2; P=.007) in patients with elevated serum free and total triiodothyronine (T(3)) levels. An initially elevated free T(3) level was a risk factor for subsequent coronary events during the 3-year follow-up (adjusted odds ratio, 4.8; 95% confidence interval, 1.3-17.4; P=.02). CONCLUSIONS: An elevation of serum free T(3) levels at hospital admission is associated with a 2.6-fold greater likelihood of the presence of a coronary event. Moreover, an initially elevated T(3) level is associated with a 3-fold higher risk of developing a subsequent coronary event during the next 3 years. Excess T(3) seemed to be a factor associated with the development and progression of acute myocardial ischemia.     

Diagnosis, incidence, and clinical significance of early postoperative ischemia after transmyocardial laser revascularization.

BACKGROUND: Clinical improvement after transmyocardial laser revascularization (TMR) is typically delayed, and patients therefore remain at risk for ischemic events after the procedure. The purpose of this study was to define the range of creatine phosphokinase (CPK) and CPK-MB enzyme elevation after TMR and to assess the incidence of early postoperative ischemic events. METHODS: Twenty-one patients undergoing isolated TMR were evaluated for 48 hours after surgery with serial CPK and CPK-MB enzymes and 12-lead electrocardiograms for evidence of myocardial ischemia or injury. Clinically evident postoperative ischemic events including angina pectoris, myocardial infarction (MI), and cardiac death were recorded as well. RESULTS: Eleven patients (52.4%) had ischemic electrocardiographic changes in the first 48 hours after TMR. Ischemia was clinically silent in 7 (63.6%) of these 11 patients. Cardiac death occurred in 1 patient (4.8%) as a result of acute MI. Nonfatal MI occurred in an additional 4 patients (19.0%). Of the 5 patients with MI, 4 had angina pectoris versus no angina in the 16 patients without MI (P =.02). All patients had elevated CPK and CPK-MB levels after TMR: however, peak CPK (P =.02) and CPK-MB (P =. 005) levels were significantly higher for patients suffering postoperative MI compared with those without MI. CONCLUSIONS: Transient ischemia occurs frequently after TMR and is clinically silent in the majority of patients. Patients with postoperative MI are more likely to have symptomatic ischemia as well as significant cardiac enzyme elevation. The combination of 12-lead electrocardiogram and cardiac enzymes appears to have significant merit for the diagnosis of myocardial ischemia and infarction after TMR. These studies should be obtained in all patients undergoing TMR for the first 48 hours after surgery.     

Unstable angina: Relationship of clinical presentation,coronary artery pathology,and clinical outcome

Patients with unstable angina are heterogeneous with respect to presentation, coronary artery morphology, and clinical outcome. Subclassification of these patients based on clinical history has been proposed as a means of identifying individuals at increased cardiac risk. We applied such a classification system to 129 patients discharged from a coronary care unit with a diagnosis of acute myocardial ischemia. Patients were then assessed for cardiac events (recurrent angina requiring revascularization, myocardial infarction, death) 12 months following hospital discharge. Patients were classified as recent onset unstable angina preinfarction (n = 42), crescendo unstable angina preinfarction (n = 48), and unstable angina postinfarction (n = 39). Within each of these groups, the patients were further subclassified based on the occurrence of angina on effort, at rest, or both. No attempt was made to subset patients taking antiischemic drugs at the time of clinical presentation to the physician. Coronary angiographic pathology (morphology and number of vessels involved) was similar in the subgroups, but coronary artery thrombus was statistically more likely to be found in patients with crescendo rest angina preinfarction or with frequent anginal episodes at rest postinfarction. Mortality was significantly higher for patients with unstable angina postinfarction (7.7%) than preinfarction (1.1%). No statistical differences were noted between the subgroups with respect to the occurrence of myocardial infarction or recurrent unstable angina requiring revascularization. These data suggest that subclassification of unstable angina patients based on clinical characteristics at presentation is not useful to predict subsequent myocardial infarction or recurrent angina requiring revascularization. However, as one might expect, patients with recurrent angina postinfarction have a higher mortality rate than patients with unstable angina preinfarction, and patients with recurrent rest angina, either pre- or postinfarction, are more likely to have intracoronary thrombus than patients with new onset angina or crescendo effort angina; however, the presence of thrombus did not predict a poor clinical outcome.