Redefining medical treatment in the management of unstable angina

In 1994, the Agency for Health Care Policy and Research sponsored the development of guidelines for diagnosing and managing patients with unstable angina. Since their publication, several important developments have occurred. The prognostic value of biochemical assays for cardiac-specific troponins T and I have been shown in many studies. The possible role for C-reactive protein in determining prognosis deserves further investigation. Substantial clinical benefits have been obtained with intravenous inhibitors of the platelet glycoprotein (GP) IIb-IIIa receptor (abciximab, eptifibatide, tirofiban) and with one of the low-molecular-weight heparins (enoxaparin). The therapeutic potential of other low-molecular-weight heparins, direct thrombin inhibitors, and oral GP IIb-IIIa inhibitors remains to be clarified. On the basis of this evidence, consideration should be given to measuring serum levels of a cardiac troponin (either T or I) and using intravenous GP IIb-IIIa inhibitors and low-molecular-weight heparin in the standard management of patients with unstable angina.     

Clinical practice guidelines of the Spanish Society of Cardiology on unstable angina/infarction without ST elevation

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.     

Clinical practice guidelines for improving outcomes in sepsis

Sepsis is a common medical condition resulting from an infectious stimulus with a variable inflammatory response leading to a spectrum of clinical conditions from mild constitutional symptoms to varying degrees of organ dysfunction and death. The understanding of the patho-physiology of sepsis has lead to better treatment modalities and whilst sepsis is an increasingly more common condition world wide, the mortality from sepsis is nevertheless falling. Treatment algorithms have been promulgated over the years and levels of evidence for these have varied. This review will focus on the early management issues recently updated and released by a multi-national panel of experts based on best evidence, aimed at reducing sepsis related mortality by 25%.     

Multiple coronary stenting in unstable angina: Early and late clinical outcomes

We examined clinical outcomes in 110 consecutive patients with unstable angina who underwent multiple coronary stenting over a 32-mo period. The main outcome measures were death, stroke, myocardial infarction, bypass surgery, and repeat angioplasty. The angiographic success rate was 100%, and the procedural success rate was 96%. There were no in-hospital deaths and five (4.5%) patients had a myocardial infarction prior to discharge. There were four (3.6%) stent thromboses with one (0.9%) patient requiring urgent bypass surgery and two (1.8%) requiring repeat angioplasty. At late follow-up (11.9 ± 7.1 mo), there was (0.9%) death and three patients (2.8%) suffered myocardial infarction. Three (2.8%) patients underwent late bypass surgery and five (4.6%) had a repeat angioplasty. At follow-up, 86% of patients were event free. We conclude that multiple coronary stenting in unstable angina may be performed with a high procedural success rate and good long-term outcome. Cathet. Cardiovasc. Diagn. 43:11–16, 1998. © 1998 Wiley-Liss, Inc.     

辛伐他汀治疗不稳定性心绞痛的临床观察

目的:探讨口服辛伐他汀早期治疗不稳定性心绞痛(UAP)对血脂及缺血事件发生的影响。方法:85例UAP 患者被随机分为治疗组(常规治疗外加服辛伐他汀,44例)和对照组(仅常规治疗,41例),于治疗前,治疗后6个月观察血脂水平及缺血事件发生率。结果:①对照组治疗前、后血脂水平无显著性变化(P>0.05),治疗组治疗后血脂水平明显下降(P<0.05);②治疗组的缺血事件明显少于对照组(P<0.05)。结论:辛伐他汀可明显降低不稳定型心绞痛患者血脂水平及缺血事件发生率。     

不稳定性心绞痛冠状动脉造影和血运重建的可行性探讨

目的研究不稳定性心绞痛的临床及介入心脏病学诊疗,并探讨其诊疗指引。方法分析包括初发型、恶化型、卧位型、变异型、中间综合征共63例不稳定性心绞痛患者的临床介入心脏病学诊疗资料,患者均行选择性冠状动脉造影。结果37例患者冠状动脉造影显示冠脉狭窄,占58.7％,其中70.3％狭窄程度大于50％,43.8％为多支冠脉狭窄。年龄、性别、病程、血脂在冠脉狭窄与非狭窄患者之间的差别无统计意义,但伴高血糖或高血压的患者冠脉狭窄发生率明显高于不伴高血糖或高血压患者。另冠脉狭窄中67.5％患者24小时动态心电图示ST下移≥0.2mV。26例冠脉狭窄大于50％的患者作了介入治疗后心绞痛消失。结论不稳定性心绞痛尤其伴高血压、高血糖或24小时动态心电图ST下移≥0.2mV患者多数有冠脉器质性狭窄,甚至为多支冠脉狭窄,其次不稳定性心绞痛易发生急性心肌梗死或猝死的潜在的病理解剖基础,应尽早行冠脉造影以便进一步治疗,必要时行介入治疗,三支病变拟行冠状动脉旁路移植术。     

Health outcomes associated with beta-blocker and diltiazem treatment of unstable angina

Objective. We compared long-term health outcomes associated with beta-adrenergic blocking agents and diltiazem treatment for unstable angina.Background. No long-term data have been published comparing these two antianginal treatments in this setting.Methods. Eligible veterans were discharged from the Veterans Affairs Puget Sound Health Care System (VAPSHCS), Seattle Division, between October 1989 and September 1995 with an unstable angina diagnosis and were prescribed monotherapy beta-blocker or diltiazem treatment at discharge. Medication data were collected from medical records and computerized VAPSHCS outpatient pharmacy files. Follow-up death and coronary artery disease rehospitalization data were collected through 1996. Proportional hazards regression compared survival among diltiazem and beta-blocker users, controlling for patient characteristics with propensity scores.Results. Two hundred forty-seven veterans (24% on beta-blockers, 76% on diltiazem) were included in this study. There were 54 (22%) deaths during an average follow-up of 51 months. After propensity score adjustment, there was no difference in risk of death comparing diltiazem to beta-blocker treatment (hazards ratios [HR] 1.1; 95% confidence interval [CI] 0.49 to 2.4). Among Washington residents (n = 207), there were 146 (71%) coronary artery disease rehospitalizations or deaths during follow-up. After adjustment, there was a nonsignificant increase in risk of rehospitalization or death associated with diltiazem use (HR 1.4; 95% CI 0.80 to 2.4). For both analyses, similar risks were found among veterans without relative contraindications to beta-blockers.Conclusions. We found no survival benefit of diltiazem over beta-blocker treatment for unstable angina in this cohort of veterans.     

Immediate and late prognosis in patients with unstable angina under medical treatment

The study was undertaken to examine 221 patients with unstable angina (UA) in the acute period and repeatedly on average of 5.3 years later. Myocardial infarction and sudden coronary death were regarded as unfavorable outcomes of UA. Out of all the patients included into the study, 33 (15%) developed myocardial infarction on days 2-28 of hospital stay, which resulted in death in 7 patients; 6 more patients died suddenly. The hospital mortality rate was 5.8%. Of 175 patients discharged from the unit, 31 developed myocardial infarction in the late period, 1 case ended with a fatal outcome, sudden coronary death was observed in 32 cases. The mortality rates by years were the following: 10.2% within the first year, 17.4% for 3 years, and 28.2% for 5 years. The choice of a complex of initial signs mostly significant for defining the risk for complications with the use of Cox's model of proportional risks indicated that the outcome of UA was affected by the following significant factors: 1) ST segment depression in the leads V4-V6; 2) duration of aggravated condition; 3) duration of coronary heart disease; 4) the number of resting anginal episodes; 5) a patient's fitness on his admission to hospital; 6) a history of arterial hypertension; 7) negative T waves in the leads V4-V5.     

Effect of conventional medical treatment on the course of unstable angina

In spite of the frequency of unstable angina, the number of clinical trials which permit to evaluate the value of conventional medical treatments, remains limited, especially because of the difficulties in finding a "specific tracer" of the efficacy of the standard drugs used. The common form of unstable angina is different from the spastic form, in that inducement tests permit, in Prinzmetal angina, better codified selection and monitoring of the patients. The literature is reviewed for each therapeutic family (calcium inhibitors, amiodarone, nitro-compounds, molsidomine, etc.). On a short term basis, the conventional treatment permits, most of the time to perform a coronary angiography under good conditions. On a long term basis, medical treatment and surgical procedure give similar results, except for patients with three-vessels disease in whom surgical revascularization provides a more comfortable life.     

不稳定性心绞痛药物保守治疗与早期介入治疗的比较

目的　探讨不稳定性心绞痛 (UA)患者的药物治疗和介入治疗与心脏事件的相关性。方法　回顾性分析 96例UA患者的临床资料 ,分为药物治疗组和介入治疗组 ,并对其进行危险分层 ,随访主要心脏事件的发生率。结果　近期随访 1个月 ,介入组与药物治疗组低、中危患者心脏事件发生率分别为 3 8%和 8 3% ,差异无显著性 ;而两组高危患者心脏事件的发生率分别为 10 %和 5 0 % ,差异有显著性 (P <0 0 5 )。 10个月随访 ,两组低、中危患者事件发生率分别为 12 5 %和 14 3% (P >0 0 5 ) ;高危患者心脏事件发生率分别为 2 0 %和 5 8 3% (P <0 0 5 )。结论　对于低、中危患者 ,介入治疗与药物治疗对心脏事件的影响差异无显著性 ,而对高危患者 ,介入治疗可明显降低近期和远期心脏事件发生率 ,提示对高危患者应及早介入治疗。     

Clinical practice guidelines of the Spanish Society of Cardiology on stable angina

Stable angina pectoris is the most common clinical manifestation of chronic ischemic heart disease, the prognosis of which depends on many factors. The authors have analyzed the incidence, evolution and prognosis of this problem in Spain and have reviewed the methods to determine the diagnosis and degree of clinical severity. A careful clinical history, an electrocardiogram, and the evaluation of the severity of the ischemia and left ventricle systolic function are, in most cases, useful to determine the degree of disease severity and establish the prognosis. In other cases, more sophisticated or complex diagnostic techniques such as perfusion tests, stress echocardiography and lastly coronary arteriography, which is the only method currently available to study coronary anatomy are required to carry out an adequate study of the patient. At present, the therapeutic arsenal for the treatment of ischemic coronary disease is extensive, from both a pharmacological and revascularization point of view. Nonetheless it is essential to carry out aggressive therapy to control the risk factors. The decision as to the type of treatment required mainly depends on the severity of the ischemia and in the case of revascularization, on the clinical and anatomical factors as well as on the preferences of the patient and the experience and results of the medical-surgical group involved in the therapy of these patients.     

Predischarge exercise echocardiography in patients with unstable angina who respond to medical treatment.

The diagnostic and prognostic value of predischarge exercise echocardiography (echo) was assessed prospectively in 36 patients with unstable angina soon after stabilization on medical treatment. Two-dimensional echo was performed at rest and immediately after a symptom-limited exercise test. Patients with previous myocardial infarction, coronary revascularization, left bundle-branch block and dilated cardiomyopathy were excluded. Left ventricular regional wall motion was analyzed visually and a wall motion score index (WMSI) was derived. Patients were followed prospectively for an average period of 26 months (range 16-34 months). The study end points were a new cardiac event defined as acute myocardial infarction or a need for coronary revascularization because of a recurrence of severe medically refractory angina. Sixteen patients (44%) had positive exercise electrocardiography (ECG), while exercise echo was positive in 22 patients (61%). Of 28 patients undergoing coronary angiography, 23 had significant coronary artery disease (CAD). The sensitivity of exercise ECG in detecting CAD was 61% while the corresponding result was 83% for exercise echo. Cardiac events occurred in 21 patients (58%). Exercise ECG was positive in 12 of these patients (57%), while a positive exercise echo was found in 17 patients (81%). There were significantly more patients with positive exercise echo among patients experiencing cardiac events than among those without cardiac events (p less than 0.01). In patients with CAD, WMSI decreased significantly after exercise (p less than 0.05). Exercise WMSI was also significantly lower in patients with CAD than in those without CAD (p less than 0.02). Exercise WMSI also discriminated patients with cardiac events from those without such events (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Continuous electrocardiographic monitoring in patients with unstable angina pectoris: evaluation of medical treatment

Sixteen patients under treatment for unstable angina (UA) were subjected to 24-hour Holter monitoring after having been asymptomatic for at least 12 hours. 12-lead ECGs were obtained every 4 hours and when anginal pain supervened. Six patients (37.50%) had no evidence of ischemia in the Holter recordings and in the 12.lead ECGs and reported no anginal pain; five (31.25%) reported no pain but had evidence of ischemia in the Holter recordings and five (31.25%) reported anginal pain and had evidence of ischemia both in the Holter recordings and in the 12-lead ECGs. The probability for a 12-lead ECG to record an episode of silent myocardial ischemia (SMI) was only 1.54 x 10(-5). Medical treatment using conventional criteria was successful in 11 patients (68.75%). If the results of Holter monitoring are considered, the success rate was 37.50% (6 out of 16 patients free from ischemia). We conclude that as Holter monitoring reveals the episodes of SMI, it is a better means for assessing the results of medical treatment.     

Inpatient treatment of unstable angina: Clinical perspective and sequential management

In the last decade, increasing information has become available to the effect that an increase in coronary artery tone and coronary artery spasm play an important role in patients with various ischemic heart disease syndromes. Coronary spasm may be superimposed on a coronary vessel already severely obstructed by atherosclerosis. Conversely, spasm may occur in an artery that is only minimally involved with atherosclerosis. The majority of patients studied in the United States with both stable and unstable angina pectoris have underlying severe organic obstructive coronary artery disease. There has now emerged a considerable amount of information from several centers showing that the calcium-channel blockers or calcium-flux antagonists are highly effective in the treatment of stable and unstable angina pectoris. This report focuses on the uses and limitations of one of these agents, nifedipine, in patients with unstable angina and provides a sequential approach to their management.     

静脉注射地尔硫治疗不稳定性心绞痛临床疗效观察

目的观察静脉地尔硫对不稳定性心绞痛（ＵＡＰ）患者的疗效与安全性。方法选择１５例严重且硝酸甘油疗效不好的ＵＡＰ患者，静注地尔硫１０～２０ｍｇ（０．２５ｍｇ／Ｋｇ体重）后，继以５～１０ｍｇ／ｈ维持４８小时。观察心绞痛症状，心电图及血流动力学变化，其中８例行漂浮导管检查。结果（１）１５例中１１例（７３．３％）ＵＡＰ患者静注地尔硫后约８．５±８．１分钟时，心绞痛症状缓解。与用药前４８小时内相比，开始用药４８小时后的心绞痛次数减少，每次最长持续时间明显缩短。（２）静脉地尔硫使１０／１５例的异常ＳＴ段恢复，３／１５明显改善。（３）静脉使用地尔硫后血压、心率降低，１０１５分钟起效，维持持续静滴的４８小时，尤其血压×心率值降低更为明显。（４）８例漂浮导管监测显示，静脉使用地尔硫中心静脉压（ＣＶＰ）短暂升高。（５）出现４例窦性心动过缓，１例一过性低血压，经处理后恢复。结论静脉地尔硫治疗对某些较顽固的ＵＡＰ有效，且相对安全。     

Effectiveness of a multifactorial strategy for implementing clinical guidelines on unstable angina: cluster randomized trial

INTRODUCTION AND OBJECTIVES. Clinical practice in unstable angina is not always based on best evidence. Guidelines have the potential to improve quality of health care. There are no randomised trials assessing implementation strategies in the public healthcare system of Spain yet. OBJECTIVE: to compare the effectiveness of a multifaceted strategy (interactive educational meetings, local consensus process) for guideline implementation in unstable angina, with a passive dissemination strategy. Patients and method. SETTING: 10 wards from 3 university hospitals in Sevilla. PARTICIPANTS: 153 specialists (cardiologists, internists) and their patients admitted for an unstable angina episode. DESIGN: a pragmatic, before and after cluster randomized controlled trial. Intervention was delivered from January to April 1998. Retrospective data collection took place in July 1999, of those pre and post-intervention episodes attended from January to October 1997 and from September 1998 to June 1999, respectively. OUTCOMES: compliance with the guideline recommendations for coronary angiography and stress testing, and ejection fraction assessment. RESULTS: The multifaceted strategy compared with the passive one, was associated with an absolute improvement in the appropriateness of use of coronary angiography and stress testing of 11% (95% CI, 0.85-21.1), P=.03. There was no association for the assessment of the ejection fraction: absolute improvement of 1.1% (95% CI, --15.9 to 18.1), P=.88. CONCLUSIONS: Our results show that a combination of interactive educational meetings and local consensus process delivered to wards of physicians may improve the appropriateness of use of coronary angiography and stress testing.