Different clinical and prognostic aspects of angina pectoris in unstable phase

The purpose of this study was to focus on the clinical and angiographic characteristics of 113 patients with crescendo angina (Group I) as compared to 187 patients with angina of new onset (Group II), selected from a series of 474 consecutive subjects, admitted to our clinic between January 1976 and July 1983 because of recurrent episodes of spontaneous angina, who underwent cardiac catheterization and coronary angiography within one month of hospitalization. Group I patients showed a greater incidence of prior transmural myocardial infarction (p less than 0.01), arterial hypertension (p less than 0.01), multivessel disease (p less than 0.01) and a lower value of left ventricular ejection fraction (p less than 0.01) than Group II patients. In the latter group of patients anginal episodes were more frequently associated with S-T segment elevation than with S-T segment depression (p less than 0.001), while the opposite was found in patients with crescendo angina. Survival curves up to five years showed that medically treated patients with crescendo angina had a worse long-term prognosis than patients with unstable angina of new onset (p less than 0.01). On the contrary no difference was found between the surgically treated patients of the two groups. Our data suggest that the more diffuse involvement of the coronary tree associated with a more depressed left ventricular function may result in an unfavorable long-term prognosis in patients with crescendo angina as compared to those with unstable angina of new onset. Such a difference between the two groups was abolished by surgical treatment.     

Clinical and angiographic correlates and prognostic significance of the coronary extent score

The clinical and angiographic correlates and the prognostic significance of the "coronary extent score" in a consecutive series of 313 patients who were catheterized twice were studied. The extent score was defined as the number of 5 to 75% stenosed segments in a 15-segment coding system. The extent score was higher in subgroups of patients with new onset angina at the time of the first angiogram (4.3 +/- 2.4 vs 3.3 +/- 1.9, p less than 0.01), unstable angina at the time of the second angiogram (4.0 +/- 2.0 vs 3.3 +/- 1.9, p less than 0.05) or multifocal progression from the first to the second angiogram (4.0 +/- 2.1 vs 3.3 +/- 1.9, p less than 0.01), suggesting that it is an index of active coronary artery disease. The extent score did not correlate with the number of diseased vessels (r = 0.03), the ejection fraction (r = 0.03), the Friesinger score (r = 0.04) and the Gensini score (r = -0.07) (difference not significant for each). Cox's model was fit to the survival data recorded on a prospective basis after the second angiogram. Independent predictors of survival were ejection fraction (p less than 0.001), extent score (p = 0.001), number of diseased vessels (p = 0.01) and percent of left main luminal stenosis (p less than 0.05). The extent score was also an independent predictor of myocardial infarction and unstable angina. Thus, the extent score, an index of active progressive disease, is an independent predictor of mortality and cardiac events in patients with coronary artery disease.     

Angiographic morphology in unstable angina pectoris

Complex morphology occurs frequently in unstable angina; however, its relation to symptomatic presentation, timing of angiography and hospital outcome has not been investigated. Accordingly, coronary angiography was performed 5 +/- 2 days after qualifying rest pain in 101 consecutive patients presenting with acute coronary insufficiency (n = 67) or crescendo angina (n = 34). Significant coronary artery disease was defined as any greater than or equal to 50% stenosis, and complex morphology as any stenosis with irregularity, overhang or thrombus. Eight of the 67 patients presenting with acute coronary insufficiency later proved to have a myocardial infarction as the qualifying event (creatine kinase twice normal with elevation of MB fraction). There were no myocardial infarctions in the crescendo angina group. Complex morphology occurred in 61% of patients. Thrombus alone occurred in 27% of patients with unstable angina without myocardial infarction, with similar frequencies between the 2 clinical groups. In contrast, intraluminal thrombi were identified in 78% of patients with acute coronary insufficiency who later proved to have a myocardial infarction as the qualifying event. The need for urgent catheterization (less than 48 hours) prompted by recurrent symptoms was associated with the angiographic findings of intraluminal thrombus (46%) and complex morphology (83%). The presence of complex morphology and intracoronary thrombus was associated with a higher incidence of in-hospital cardiac events, i.e., revascularization, myocardial infarction and death, independent of the incidence of multivessel disease.     

Short and long term outcome of percutaneous transluminal coronary angioplasty in unstable versus stable angina pectoris: a report of the 1985-1986 NHLBI PTCA Registry

In a cohort of 1,720 consecutive patients from the National Heart, Lung, and Blood Institute, Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry (August 1985-May 1986), we compared 768 patients (45%) with stable angina and 952 patients (55%) with unstable angina pectoris. Unstable angina patients exhibited at least one of the following characteristics: new onset angina, rapidly progressing angina, angina at rest, angina refractory to medication, variant angina, acute coronary insufficiency, or angina recurring shortly after an acute myocardial infarct. The distribution of single- and multi-vessel disease was similar among stable and unstable angina patients; multi-vessel disease predominated. Average severity of stenosis and incidence of tubular and diffuse stenosis morphology were higher among patients with unstable angina (both p less than 0.001). Patient success rates were similar in stable and unstable patients. However, on a per lesion basis, overall angiographic success rate and average reduction of severity of stenosis in successfully dilated lesions were significantly higher among patients with unstable angina (both p less than 0.001). Incidence of major patient complications (p less than 0.01) and of emergency coronary bypass surgery (p less than 0.05) were also higher in patients with unstable angina but consistent with their more precarious clinical condition and stenosis morphology. During a two year follow-up, the cumulative distributions of death, myocardial infarct, repeat PTCA, and coronary bypass surgery were not significantly different in patients with stable angina compared to patients with unstable angina. Comparison of the current PTCA Registry cohort with the cases reported in the 1979-1982 Registry revealed a 19% higher success rate for both stable and unstable angina patients. Major complication rates decreased between time periods for stable but not for unstable angina patients. Incidence of emergency bypass surgery decreased more for stable than for unstable angina patients. Coronary angioplasty is indicated in properly selected patients with unstable angina and both single- and multi-vessel coronary disease.     

The prognostic importance of asymptomatic ischemic episodes in patients with unstable angina pectoris

Unstable angina pectoris is a high-risk ischemic disease which is characterized by recent onset of angina, a change in preexisting stable angina pattern or the occurrence of angina at rest. In a study of 70 patients with unstable angina on treatment with a triple drug regimen of nitrates, propranolol and nifedipine, 37 patients (53%) had 205 ischemic episodes, 90% of which were asymptomatic. 33 patients (47%) had no changes in the ST-segments. Between the two groups, there were no significant differences with respect to risk factors, medical treatment or coronary angiographic findings. Only the resting ejection fraction in the former group was slightly but significantly lower than in the latter group. At one month of follow-up seven patients had developed myocardial infarction, six of whom were in the group with silent ischemia. In 13 patients, due to inadequate success of medical treatment, bypass surgery or PTCA was performed; ten of these were from the group with silent ischemia. Of patients with silent ischemia, those with episodes totaling more than 60 minutes per 24 hours had the worst outcome. Multivariate analysis showed that, with respect to prognosis, the most important parameter was silent ischemia followed by angina pectoris.     

Clinical and angiographic factors associated with progression of coronary artery disease

To characterize the clinical and angiographic factors associated with progression of coronary atherosclerosis, 313 consecutive medically treated patients who had had two coronary arteriograms 3 to 119 months (mean 39 +/- 25) apart were studied. One hundred eighty-one patients underwent recatheterization for stable angina, 52 for unstable angina and 80 for various other reasons. In addition to the conventional angiographic features present at the first angiographic study (number of diseased vessels 1.5 +/- 0.8, ejection fraction 59 +/- 11%), an extent score was defined based on the number of coronary segments with 5 to 75% narrowings from a 15 segment coding system. Multivariate logistic regression identified four independent predictors of progression of coronary artery disease: the interval between studies (p less than 0.0001), unstable angina (p less than 0.0001), a high extent score (p = 0.0001) and young age (p = 0.0026). In a subset of 74 patients aged 50 years or younger with, at the time of the first evaluation, an extent score of 4 or more, the probability of progression between 2 and 4 years and after 4 years was, respectively, 80 and 90% compared with 50% for the other patients. Risk stratification for progression of coronary artery disease can thus be obtained.     

Role of previous angina pectoris and collateral flow to preserve left ventricular function in the presence or absence of myocardial infarction in isolated total occlusion of the left anterior descending coronary artery

The aim of this study was to determine whether previous angina pectoris and collateral circulation influenced myocardial function after isolated coronary occlusion. In 58 consecutive patients, coronary angiography showed a complete isolated occlusion of the left anterior descending coronary artery; 43 patients (74%) had previous myocardial infarction. Duration of previous angina pectoris was defined as the time from the first ischemic symptom to the date of myocardial infarction or of coronary angiography in the absence of myocardial infarction. Left ventricular ejection fraction was measured on the 30 degrees right anterior oblique projection of the left ventricular angiogram. Collateral circulation was graded as follows: none or filling limited to side branches (group 1) and partial or complete filling of the epicardial arterial segment (group 2). Group 2 (40 patients) had higher ejection fraction (57 vs 38%; p less than 0.0001) and longer duration of previous angina pectoris (11 vs 0.1 months; p less than 0.002) than group 1 (18 patients). A longer duration of previous angina pectoris probably allows collateral development before coronary occlusion in 1-vessel coronary artery disease, thereby limiting myocardial damage.     

Clinical and angiographic findings in angina at rest

The purpose of this study was to delineate the clinical, ECG, and angiographic features of a large series of consecutive patients with angina at rest. Transient ST segment elevation during pain was observed in 219 patients (group I), while 220 patients showed ST segment depression during pain (group II). Group II patients were found to have higher incidence of hypertension (p less than 0.001), prior myocardial infarction (p less than 0.0005), history of exertional angina (p less than 0.0005), and a progressive aggravation of symptoms before hospitalization (p less than 0.0005), while group I patients had a prevalence of recent onset angina (p less than 0.05) and more frequently developed severe ventricular arrhythmias during pain (p less than 0.0005). Furthermore, a larger number of patients showing ST segment depression during chest pain had multivessel disease (p less than 0.0005), left main involvement (p less than 0.005), and lower values of left ventricular ejection fraction (p less than 0.001) than patients with ST segment elevation during pain. Survival curves of medically treated patients showed a significantly better long-term prognosis in patients of group I (p less than 0.01). The direction of the ST segment shift during anginal attacks at rest may therefore allow a classification of patients included into the broad spectrum of unstable angina. This distinction should be taken into consideration in studies aimed at evaluating long-term prognosis or the results of medical and surgical therapy.     

Angiographic coronary artery lesion morphology and pathogenetic mechanisms of myocardial ischemia in stable and unstable coronary artery disease syndromes.

The angiographic morphology of coronary artery stenoses was studied in 160 patients referred for diagnostic coronary arteriography. Three groups of patients were studied: 60 patients with stable angina, 78 patients with unstable angina and 22 patients with a recent myocardial infarction. Complex lesions were more frequently observed in patients with unstable angina (59%, p less than 0.001) and in patients with a recent myocardial infarction (54%, p less than 0.05) then in patients with stable angina (25%). Angiographic signs suggestive for the presence of intravascular thrombi were almost exclusively observed in the patients with unstable angina (34%, p less than 0.001) and in the patients with a recent myocardial infarction (27%, P less than 0.001) and were almost completely absent in the patients with stable angina (1.5%). The high prevalence of complex coronary artery lesion morphology and of intravascular thrombi observed in patients with unstable angina or with a recent myocardial infarction emphasizes the important role of intima disruption and of subsequent thrombosis in the pathogenesis of myocardial ischemia in those unstable syndromes of ischemic heart disease.     

Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease.

Of 88 consecutive patients aged 20 to 77 years with severe symptomatic aortic valve disease requiring surgery, 51 patients had angina pectoris; of these 51, 41 had predominant aortic stenosis and 10 had severe aortic regurgitation. All patients with angina pectoris underwent coronary angiography; significant coronary arterial disease was encounted in 24 per cent of those with aortic stenosis and 20 per cent of those with aortic regurgitation. By contrast, of 37 patients without angina pectoris 19 underwent coronary arteriography; none showed significant coronary artery disease (P smaller than 0.05). Among patients with angina pectoris, 17 per cent of those with aortic stenosis experienced prolonged, rest or nocturnal pain, compared to 70 per cent of those with aortic regurgitation (P smaller than 0.005). At the time of onset of angina pectoris, there were features of heart failure in 34 per cent of those with aortic stenosis, and in 90 per cent of those with aortic regurgitation (P smaller than 0.005). Nitroglycerin promptly relieved angina pectoris in 56 percent of patients with aortic stenosis and in 50 per cent of those with aortic regurgitation (P smaller than 0.05). Neither the pattern of angina pectoris nor the response to nitroglycerin was dependent upon the coexistence of significant coronary artery disease. In patients with aortic stenosis, there was not significant difference between those with angina pectoris, and those without angina with regard to left ventricular end-diastolic volume, end-diastolic pressure, ejection fraction, peak systolic pressure, wall thickness, cardiac index, or the product of these factors. In patients with aortic regurgitation, cardiac index was significantly lower (P smaller than 0.05), left ventricular end-diastolic volume tended to be larger, and ejection fraction tended to be lower in patients with angina pectoris as opposed to those without angina pectoris.     

Comparison of the data of 24-hour ECG monitoring and the condition of the coronary bed in patients with the variants of the course of unstable stenocardia]

A total of 232 patients with various clinical types of unstable angina pectoris were examined. All the patients underwent coronary angiographic studies, 24-hour ECG monitoring. In 40.5% of the patients, 24-hour monitoring revealed transient ST segment changes which were not accompanied by pain in 47% of the cases. ST segment changes were equally encountered in patients with one-, two-, and three-vessel disease in the presence or absence of pain. Ischemic ST segment changes generally occurred with an anginal episode in patients with crescendo unstable angina, whereas in those with more prolonged and intensified pain and angina at rest in particular, silent myocardial ischemic episodes were significantly more frequently recorded, which were more common in these patients with multivessel disease.     

Modification of risk factors through physical training and low-fat diet

This intervention program investigated the applicability and the effects of intensive physical exercise and low-fat diet on the progression of coronary atherosclerotic lesions and stress induced myocardial ischemia in patients with stable angina pectoris. Patients participating in this study were recruited following routine coronary angiography for angina pectoris. Inclusion criteria were male sex, stable symptoms, a willingness to participate in the study for at least twelve months, and coronary artery stenoses well documented by angiography. Exclusion criteria were unstable angina pectoris, left main coronary artery stenosis greater than 25% luminal diameter reduction, severely depressed left ventricular ejection fraction (less than 35%), significant valvular heart disease, insulin-dependent diabetes mellitus, primary hypercholesterolemia (type II hyperlipoproteinemia, low-density lipoprotein greater than 210 mg/dl), and conditions precluding regular physical exercise. 18 patients participated in this program for one year; they consumed a low-fat, low-cholesterol diet (less than 20 energy % fat, cholesterol less than 200 mg/day) and exercised for more than 3 h/week. Myocardial oxygen consumption was estimated from maximum rate-pressure product at peak exercise; it was correlated to stress induced myocardial ischemia, as measured by 201Tl-scintigraphy. Results were compared with those of 18 matched patients on "usual care". In the intervention group, physical work capacity (161 +/- 34 W vs. 194 +/- 42 W) and maximum rate pressure product (25.0 +/- 6.3 x 10(3) vs. 27.2 +/- 5.3 x 10(3)) increased significantly (p less than 0.01). Patients willing to devote time and effort to intensive physical exercise and to comply with a low-fat diet may benefit from this form of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Short- and long-term efficacy of high-dose oral diltiazem for angina due to coronary artery disease: a placebo-controlled, randomized, double-blind crossover study

The effects of oral diltiazem (360 mg/day) on exercise tolerance, left ventricular performance, and plasma lactate and catecholamine levels were studied in 13 patients with atherosclerotic coronary artery disease in a placebo-controlled, randomized, double-blind protocol. Exercise duration to the onset of ischemic ST segment depression, time to angina pectoris, and time to peak exercise improved by 120, 174, and 144 sec, respectively (p less than .0001). Left ventricular ejection fraction, as determined by radionuclide angiography, increased in patients at rest from 52 +/- 11% (mean +/- SD) during placebo therapy to 58 +/- 11% during diltiazem therapy (p less than .001); at peak exercise ejection fraction increased from 44 +/- 11% during placebo treatment to 52 +/- 15% during diltiazem therapy (p less than .01). The mean plasma norepinephrine level in patients at rest increased from 498 +/- 221 pg/ml during placebo treatment to 667 +/- 272 pg/ml during diltiazem therapy (p less than .05). Resting standing blood pressure and supine and standing diastolic blood pressures decreased significantly with diltiazem. In all 10 patients followed over a long term, oral diltiazem caused persistent improvement in exercise performance at 12 to 20 weeks, without evidence of placebo effects. Thus, diltiazem is highly effective in divided doses of 360 mg/day for the therapy of chronic angina pectoris due to coronary artery disease.     

Results of repeated coronary angiography in patients with unstable angina pectoris in a long-term follow-up

A total of 27 patients with unstable angina pectoris were examined in the acute period of the disease and 3.4 years later (from 30 to 51 months). A group of patients with a favorable outcome of unstable angina comprised 13 patients who had displayed no recurrences of disease exacerbation, but that of patients with an unfavorable outcome of unstable angina consisted of 14 patients who had had recurrences of symptoms of progressive angina until myocardial infarction (in 6 patients). Coronary angiography made during the first hospitalization showed that 40% of the patients exhibited a "complicated lesion" of the symptom-related artery, which further transformed to an uncomplicated one (Type I stenosis according to the classification by J. Ambrose et al.), the remaining developed coronary occlusion. Comparison of the specific features of a course of the disease and coronary angiographic findings revealed no relationship between the degree of symptom-related artery stenosis and the long-term outcome of unstable angina.     

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.     

稳定型与不稳定型心绞痛冠状动脉造影特点的对比分析

目的:分析稳定型与不稳定型心绞痛患者的冠脉造影特点,评估不稳定型心绞痛的危险性并指导其临床治疗和预后判断。方法:选择在我院进行冠脉造影的80例稳定型心绞痛和136例不稳定型心绞痛(初发劳力性、恶化劳力性、静息性)患者,并对所有冠脉造影结果进行对比分析。结果:初发劳力性心绞痛单支病变较其它组心绞痛多见(P<0.05);恶化劳力性、静息性心绞痛左主干病变较初发劳力性多见(P<0.05);稳定型心绞痛冠脉病变形态以A型病变多见,不稳定型心绞痛以C型病变多见,两者之间有着显著性差异(P<0.01);不稳定型心绞痛总的血栓检出率高于前者(P<0.05)。结论:不稳定型心绞痛患者冠脉病变较稳定型心绞痛患者冠脉病变形态复杂、血栓发生率高,病变的不稳定导致其病情严重、预后差。     

Angiographic observations and clinical relevance of coronary thrombus in unstable angina pectoris

To assess the mechanisms of unstable angina, the coronary angiographic studies in 69 patients with severe unstable angina (prolonged pain or pain at rest) and in 20 patients with stable angina were blindly reviewed to assess the coronary morphologic changes in these syndromes. Coronary angiography was performed an average of 1.7 days from admission and an average of 24 hours from last symptoms of chest pain in patients with unstable angina. Angiographic studies were analyzed for evidence of coronary thrombus (intraluminal filling defects) at significant stenoses in patent vessels or thrombus at sites of total occlusion) and for coronary lesion morphology suggesting a complex or acute lesion (irregular or ill-defined margins, inhomogeneity, haziness or ulceration). Angiographic evidence of coronary thrombus was present in 40 of 69 patients (58%) with unstable angina: 31 (45%) had intraluminal filling defects and 9 (13%) had thrombotic total occlusion with well-developed collaterals present. Only 1 of 20 patients (5%) with stable angina had evidence of thrombus (p less than 0.001). Complex lesions were present in 18 other unstable patients (26%) and in 2 other patients (10%) with stable angina who did not have angiographic evidence of thrombus. Overall, 58 of 69 patients (84%) with unstable angina had morphologic findings suggesting an acute process (thrombus or complex lesion) compared with 3 of 20 patients (15%) with stable angina, p less than 0.0001. Thus, unstable angina is associated with a high prevalence of angiographic coronary thrombus and complex lesions suggesting an acute process, in contrast to stable angina.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of nifedipine and isosorbide dinitrate when added to maximal propranolol therapy in stable angina pectoris

A study was performed to compare isosorbide dinitrate and nifedipine as adjunctive therapy in 14 patients with coronary artery disease and stable angina pectoris taking maximal beta-blocking drugs. Drug titration phases ensured maximal therapy of propranolol, isosorbide or nifedipine. The combination of nifedipine and propranolol was more effective than the combination of isosorbide and propranolol in reducing angina and increasing exercise capacity (323 vs 416 seconds, p less than 0.005) during exercise treadmill testing. Nifedipine produced a greater reduction in systolic blood pressure at submaximal exercise than isosorbide. Global and regional ejection fraction at rest and exercise was assessed with radionuclide ventriculography. The substitution of nifedipine for isosorbide depressed the global ejection fraction at rest (0.61 to 0.56 p less than 0.05) and produced a slight improvement in exercise ejection fraction (0.47 to 0.51, difference not significant). The decrease in ejection fraction from rest to exercise was 0.14 to 0.04 with nifedipine (p less than 0.005). The benefit of nifedipine compared with isosorbide occurred in regions with marked exercise-induced ischemia. In patients treated with maximal beta-blocking therapy, nifedipine is an effective alternative to isosorbide as a combination agent with propranolol. The salutary effects of nifedipine included afterload reduction with exercise and possible improvements in coronary blood supply.     

Immediate and follow-up results of the conservative coronary angioplasty strategy for unstable angina pectoris.

To assess the results of a conservative coronary angioplasty strategy in unstable angina pectoris, the records of 1,421 consecutive patients without previous myocardial infarction undergoing a first percutaneous transluminal coronary angioplasty (PTCA) between 1986 and 1990 were reviewed. Of these patients, 631 had unstable and 790 had stable angina pectoris. Only after an intense effort to medically control symptoms, the unstable patients underwent PTCA at an average of 15.4 days (range 1 to 76) after hospital admission. Primary clinical success was achieved in 91.7% of patients with unstable and in 94.4% of those with stable angina pectoris (p = not significant). In-hospital mortality rates were 0.3 and 0.1%, respectively (p = not significant). Nonfatal in-hospital event rates for acute myocardial infarction, cerebrovascular accident and coronary bypass surgery were only slightly higher in patients with unstable angina pectoris; however, the difference from the stable group was significant when all events were combined (9 vs 5.9%; p less than 0.04). During 6-month follow-up, no significant difference in adverse events was found between the groups. The respective rates for the unstable and stable groups were 0.4 and 0.2% for death, 5.5 and 5.1% for major nonfatal events, and 17.7 and 20.1% for repeat PTCA. These results suggest that use of a conservative PTCA strategy in the treatment of patients with unstable angina pectoris results in favorable and similar immediate and 6-month outcomes compared with those in patients with stable angina pectoris.