Percutaneous angioscopy during coronary angioplasty using a steerable microangioscope

The feasibility of using a flexible, steerable angioscope to perform coronary angioscopy before and after percutaneous coronary angioplasty was tested. The microangioscope fits through an 8F coronary angioplasty guiding catheter and contains a multifiber viewing bundle incorporated into the body of a 4.3F balloon catheter with a central lumen for distal flushing and guide-wire passage. Angioscopy was performed without complications 45 times in 24 patients, including 6 patients with stable and 18 with unstable angina. Circumferential visualization of the target lesion was successful in 20 (83%) of the 24 patients and improved with operator experience. Excellent visualization of the target lesion was achieved in 16 (94%) of the last 17 patients. Plaque, thrombus and dissection were among the abnormal findings in the 20 patients (4 with stable, 16 with unstable angina) in whom circumferential viewing of the target lesion was achieved. In four patients with restenosis after angioplasty, the lesion morphology was distinctly different from that of lesions in arteries without prior angioplasty. In patients with stable angina, no thrombus or dissection was seen by angiography or angioscopy before angioplasty. In patients with unstable angina, thrombus was detected more frequently by angioscopy than by angiography before angioplasty (8 versus 2 of 16) and after (15 versus 2 of 16) angioplasty. Intimal dissection was also seen much more frequently by angioscopy than by angiography before angioplasty (7 versus 0 of 16) and after angioplasty (16 versus 7 of 16). It is concluded that high resolution percutaneous coronary angioscopy can be performed safely in conjunction with balloon angioplasty. Further investigation is needed before this diagnostic tool can be applied clinically.     

不稳定性心绞痛患者冠状动脉内粥样斑块的稳定性与血栓形成关系的探讨

目的　应用冠状动脉血管内视镜技术对不稳定性心绞痛(unstableanginapectoris, UA)患者的罪犯血管内粥样斑块的稳定性与血栓形成之间的关系进行探讨,为研究急性冠状动脉综合征(acutecoronarysyndromes, ACS)的发生提供临床病理基础。方法　选择UA患者68例,男性48例,女性20例,年龄40~73(62.4±8 .6)岁,除外心肌梗死后心绞痛和变异性心绞痛患者。上述患者在进行冠状动脉介入性检查和治疗的同时,对其“罪犯”血管进行血管内视镜检查。结果　(1) 68例患者(68支“罪犯”血管)中均观察到粥样斑块(100% ),其中有血栓者63例(92 .7% ),有内膜损伤者46例(67. 7% )。(2)68例冠状动脉粥样斑块者中,黄色斑块者48例( 70 .5% ),淡黄色斑块者18例(26. 5% ),白色斑块者2例(2. 9% )。(3)63例血栓均为附壁性非闭塞性血栓,其中红色或混合性血栓11例(17. 5% ),白色或粉红色血栓52例(82. 5% )。(4)46例内膜损伤者中均可见到血栓形成,其中红色或混合性血栓11例(23.9% ),白色或粉红色血栓35例(76. 1% )。结论　在UP患者中观察到黄色不稳定性斑块破裂及其伴随的血栓形成,是引起UA的病理基础。因此,在黄色斑块破裂之前采取何种治疗措施使其稳定化,是预防ACS的关键。     

Association between complex coronary artery stenosis and unstable angina and the extent of plaque inflammation

PURPOSE: Patients with unstable coronary syndromes often have complex morphology of coronary stenoses at angiography. We evaluated the association between qualitative assessment of coronary stenoses and plaque inflammation determined by immunohistochemistry. METHODS: A total of 79 patients with unstable (n = 46) or stable angina (n = 33) underwent directional coronary atherectomy for culprit lesions. Qualitative analysis of coronary angiograms was performed using a modified Ambrose classification. Coronary lesions were categorized as either simple (concentric and eccentric type I, n = 29) or complex (eccentric type II and multiple irregularities, n = 50). Cryostat sections of retrieved atherosclerotic specimens were stained immunohistochemically with monoclonal antibodies, alpha-actin (smooth muscle cells), CD68 (macrophages), and CD3 (T lymphocytes). The extent of atherosclerotic inflammation within each coronary lesion was determined by the percentage of immunopositive macrophages per total tissue area (including smooth muscle cells) and the number of T lymphocytes per mm(2). RESULTS: The mean (+/- SD) percentage of macrophages in atherectomy specimens from patients with unstable angina was greater than in specimens from patients with stable angina (21% +/- 14% vs. 13% +/- 10%, P = 0.01); similar results were seen when complex coronary lesions were compared with simple lesions (23% +/- 13% vs. 9% +/- 8%, P <0.001). In multivariate linear regression models, the combination of unstable angina and lesion complexity was strongly associated with the percentage of plaque macrophages. CONCLUSION: The extent of atherosclerotic plaque inflammation is associated with angiographic grading of coronary lesion complexity and unstable angina.     

High yellow color intensity by angioscopy with quantitative colorimetry to identify high-risk features in culprit lesions of patients with acute coronary syndromes

High yellow color intensity (HYCI) regions of atherosclerotic plaque, determined by angioscopy with quantitative colorimetry, are associated with lipid cores underneath thin fibrous caps in ex vivo tissue samples. To determine whether HYCI regions of coronary plaque are associated with disruption or thrombus in living patients, quantitative colorimetry was applied to angioscopy, and the color of culprit lesions was measured in patients with acute coronary syndromes. In 46 patients with acute coronary syndromes (acute myocardial infarction, n = 14; unstable angina pectoris [UAP] with culprit thrombus, n = 16; and UAP without culprit thrombus, n = 16), the recorded angioscopic images of culprit lesions were analyzed using a quantitative colorimetric method based on the L*a*b* color space applied to angioscopy (positive b* = yellow color intensity). HYCI was defined as b* value >23. Plaque disruption was significantly more prevalent in 19 of 24 HYCI regions (79%) than in 9 of 22 non-HYCI regions (41%) (p = 0.007). Culprit HYCI regions were prevalent in patients with myocardial infarction (11 of 14 [79%]), followed by those with UAP with thrombus (9 of 16 [56%]) and UAP without thrombus (4 of 16 [25%]) (p = 0.01 for trend), and were significantly more prevalent in 66% of patients with myocardial infarction and UAP with thrombus compared with 25% of those with UAP without thrombus (p = 0.007). In conclusion, HYCI regions of coronary plaque may be indicative of high-risk lesions vulnerable to thrombosis. Coronary angioscopy with quantitative colorimetry could be used to study the association between high-risk coronary lesions and future cardiovascular events.     

Angioscopic predictors of restenosis following coronary angioplasty--the impact of yellow smooth plaques

Despite angioscopy being used for more than 10 years, data regarding the prognostic significance are still limited. This study evaluated the prognostic relevance of the angioscopic lesion morphology and plaque colour on restenosis rate following coronary angioplasty. Out of 66 patients with coronary angioscopy prior to an angioplasty procedure, 46 patients with successful balloon dilation and 16 patients with stenting were included into the study. Angioscopic plaque morphology and plaque colour were correlated with the anginal status, the angiographic lesion morphology, the procedural result, and the restenosis rate during six months follow-up. Clinical follow-up was obtained from all patients, re-angiography was performed in 61%. Angioscopically complicated lesions were more frequent in patients with unstable versus stable angina (63% versus 28%, p < 0.005) and ACC/AHA type B2/C versus A/B1 stenoses (86% versus 7%, p < 0.03). In addition yellow plaques were more often seen in unstable versus stable angina (80% versus 50%, p < 0.02) and in type B2/C versus A/B1 lesions (81% versus 47%, p < 0.005). There were no deaths or myocardial infarctions during follow-up. Restenosis (n = 11) occurred significantly more frequent in patients with smooth, yellow lesions (37%) compared to all other lesion morphologies (9%, p < 0.02). Logistic regression analysis revealed angioscopically smooth, yellow plaques (p < 0.05) and angiographically type B2/C lesions (p < 0.03) as independent predictors for restenosis. We conclude that angioscopically smooth, yellow plaques covered by an intact inner vessel surface are associated with a higher incidence of restenosis following coronary angioplasty, potentially indicating a higher proliferative response after a mechanical trauma of such lesions.     

Plaque disruption and thrombus in Ambrose's angiographic coronary lesion types

Lesion eccentricity with irregularities on coronary angiography is associated with ruptured plaques and thrombus based on postmortem and clinical angiographic studies. However, the predictive value of such angiographic markers of plaque disruption and thrombus remains to be determined in vivo. The purpose of this study was to establish whether Ambrose's angiographic coronary lesion types and other angiographic criteria predict the presence of disrupted plaques and thrombus using intracoronary angioscopy. Angioscopy was performed before angioplasty in 60 patients with various coronary syndromes and culprit lesions that were not totally occlusive. Lesions were classified angiographically according to Ambrose's criteria as concentric, type I and II eccentric, and multiple irregularities, or as complex or noncomplex, and then compared with the corresponding angioscopic findings. Disruption and/or thrombus were seen in 17 of 19 type II eccentric lesions and 21 of 23 angiographically complex lesions and had the highest positive predictive value to detect complicated atherosclerotic plaques (type II eccentric lesions: positive predictive value 89%, 95% confidence intervals 67% to 99%; complex lesions: 91%, 95% confidence intervals 72% to 99%). We conclude that Ambrose's type II eccentric stenoses and angiographically complex lesions are strongly associated with disrupted plaques and/or thrombus as assessed by angioscopy in patients and represent unstable plaque substrates.     

50th anniversary historical article. Acute coronary syndromes: the degree and morphology of coronary stenoses

In 110 patients with either stable or unstable angina, the morphology of coronary artery lesions was qualitatively assessed at angiography. Each obstruction reducing the luminal diameter of the vessel by 50% or greater was categorized into one of the following morphologic groups: concentric (symmetric narrowing); type I eccentric (asymmetric narrowing with smooth borders and a broad neck); type II eccentric (asymmetric with a narrow neck or irregular borders, or both); and multiple irregular coronary narrowings in series. For the entire group, type II eccentric lesions were significantly more frequent in the 63 patients with unstable angina (p less than 0.001), whereas concentric and type I eccentric lesions were seen more frequently in the 47 patients with stable angina (p less than 0.05). Type II eccentric lesions were also present in 29 of 41 arteries in patients with unstable angina compared with 4 of 25 arteries in those with stable angina (p less than 0.0001) in whom an "angina-producing" artery could be identified. Therefore, type II eccentric lesions are frequent in patients with unstable angina and probably represent ruptured atherosclerotic plaques or partially occlusive thrombi, or both. A temporary decrease in coronary perfusion secondary to these plaques with or without superimposed transient platelet thrombi or altered vasomotor tone may be responsible for chest pain in some of these patients with unstable angina.     

Angiographic morphology and the pathogenesis of unstable angina pectoris

In 110 patients with either stable or unstable angina, the morphology of coronary artery lesions was qualitatively assessed at angiography. Each obstruction reducing the luminal diameter of the vessel by 50% or greater was categorized into one of the following morphologic groups: concentric (symmetric narrowing); type I eccentric (asymmetric narrowing with smooth borders and a broad neck); type II eccentric (asymmetric with a narrow neck or irregular borders, or both); and multiple irregular coronary narrowings in series. For the entire group, type II eccentric lesions were significantly more frequent in the 63 patients with unstable angina (p less than 0.001), whereas concentric and type I eccentric lesions were seen more frequently in the 47 patients with stable angina (p less than 0.05). Type II eccentric lesions were also present in 29 of 41 arteries in patients with unstable angina compared with 4 of 25 arteries in those with stable angina (p less than 0.0001) in whom an "angina-producing" artery could be identified. Therefore, type II eccentric lesions are frequent in patients with unstable angina and probably represent ruptured atherosclerotic plaques or partially occlusive thrombi, or both. A temporary decrease in coronary perfusion secondary to these plaques with or without superimposed transient platelet thrombi or altered vasomotor tone may be responsible for chest pain in some of these patients with unstable angina.     

Acute coronary syndromes: the degree and morphology of coronary stenoses

In 110 patients with either stable or unstable angina, the morphology of coronary artery lesions was qualitatively assessed at angiography. Each obstruction reducing the luminal diameter of the vessel by 50% or greater was categorized into one of the following morphologic groups: concentric (symmetric narrowing); type I eccentric (asymmetric narrowing with smooth borders and a broad neck); type II eccentric (asymmetric with a narrow neck or irregular borders, or both); and multiple irregular coronary narrowings in series. For the entire group, type II eccentric lesions were significantly more frequent in the 63 patients with unstable angina (p less than 0.001), whereas concentric and type I eccentric lesions were seen more frequently in the 47 patients with stable angina (p less than 0.05). Type II eccentric lesions were also present in 29 of 41 arteries in patients with unstable angina compared with 4 of 25 arteries in those with stable angina (p less than 0.0001) in whom an "angina-producing" artery could be identified. Therefore, type II eccentric lesions are frequent in patients with unstable angina and probably represent ruptured atherosclerotic plaques or partially occlusive thrombi, or both. A temporary decrease in coronary perfusion secondary to these plaques with or without superimposed transient platelet thrombi or altered vasomotor tone may be responsible for chest pain in some of these patients with unstable angina.     

Prevalence of Chlamydia pneumoniae in the atherosclerotic plaque of patients with unstable angina and its relation with serology

BACKGROUND: Chlamydia pneumoniae has been associated with coronary artery disease by both seroepidemiological studies, and by direct detection of the micro-organism in atherosclerotic lesions. This bacteria could play a potential role in the development of acute coronary events. We examined coronary arteries from patients with unstable angina in order to verify an endovascular presence of C. pneumoniae, and to determine if there is any relationship between serology of acute infection by this pathogen and its presence inside the atherosclerotic plaque of these patients. METHODS: We analysed a total of 76 atherosclerotic plaques obtained from 45 patients who underwent coronary artery bypass surgery. In all patients unstable angina was present within the prior 3 weeks. The presence of C. pneumoniae in the plaque was determined by nested polymerase chain reaction (PCR). Antichlamydial immunoglobulin G (IgG), A (IgA) and M (IgM) was examined by microimmunofluorescence and compared to the PCR result. FINDINGS: DNA of C. pneumoniae was detected in 57 (75%) of 76 atherosclerotic lesions. In most cases (74/76: 97%) a positive IgA, IgM or IgG result was seen. Seven (12%) and 54 (94%) of the 57 PCR positive plaques came from patients with a positive IgM and IgA result, respectively. There was no statistical significant difference between PCR positive and PCR negative plaques in patients with a positive or negative serological result. Clinical characteristics were similarly distributed in patients with and without infected lesions. INTERPRETATION: C. pneumoniae organisms are frequently found in the atherosclerotic lesions of patients undergoing coronary surgery for unstable angina. Neither serological results of acute or recent infection by C. pneumoniae nor clinical characteristics are useful in predicting the individual risk of harbouring C. pneumoniae in the coronary lesions of patients with unstable angina.     

Angiographic morphology of coronary lesions in various syndromes of ischemic cardiopathy

The angiographic morphology of coronary lesions is often completely ignored in the prognostic and decision-making process related to patients with coronary disease. We performed this study to evaluate the possibility of identifying complex or complicated atherosclerotic lesions by means of routine diagnostic coronary arteriography, and to assess their prevalence in the different syndromes of ischaemic heart disease. From an overall group of 200 successive cases studied using coronary angiography, 111 patients with significant coronary artery disease in whom a "culprit lesion" could be identified were retrospectively selected. The angiographic morphology of coronary lesions was defined according to an original classification as: 1) simple stenosis, 2) complex lesion, 3) thrombosis. Of the 111 patients, 36 had been studied for stable angina, 31 for unstable angina, 10 for a non-Q wave myocardial infarction, 34 for transmural infarction. The clinical groups did not show any significant differences when compared on the basis of number of vessels involved and degree of narrowing of the ischaemia-producing artery. Significant differences were found when angiographic morphology was analyzed. In stable angina 78% of ischaemia producing lesions appeared as simple stenoses, while 92% of the unstable or more severely ischaemic patients exhibited complicated lesions (p less than 0.001). In unstable angina and non-Q infarction a complex lesion was present respectively in 71% and 60% of the cases; clear-cut intraluminal thrombosis was demonstrated in 23% of unstable angina, in 30% of non-Q wave infarction and in 39% of transmural infarction (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Morphometric analysis of coronary lesions in patients with unstable angina--an arteriographic study.

In 100 patients with unstable angina and 50 patients with stable angina qualitative morphology of coronary artery lesions were compared by angiography. The mean age of the patients was 51 years. In the unstable angina group, 50 patients had rest angina, 32 had crescendo angina and 18 had denovo angina; 31 patients had single vessel disease, 33 had two vessel disease, 34 had triple vessel disease and 2 had left main disease. 'Angina-producing' artery could be identified in 90 out of 100 patients. Ten totally occluded vessels were excluded from analysis. Lesions causing diameter stenosis of greater than 50% could be categorised to one of the following groups: a) Concentric stenosis (18 vessels), b) Type I eccentric lesion (asymmetric narrowing with smooth borders and broad neck--20 vessels), c) Type II eccentric lesion (asymmetric narrowing with narrow neck and overhanging irregular edges--47 vessels), and d) Multiple irregularities (15 vessels). Lesions in 9 vessels showed an associated thrombus. It appears that Type II eccentric lesions are frequent in patients with unstable angina; they probably represent ruptured atherosclerotic plaque or partially occlusive thrombi or both.     

急性冠状动脉综合征患者不稳定性斑块的血管内超声

目的观察急性冠状动脉综合征患者不稳定性斑块的血管内超声特征.方法 36例急性冠状动脉综合征患者和20例稳定型心绞痛患者进行冠状动脉造影及血管内超声检查.应用血管内超声分别观察比较冠状动脉内斑块的性质,同时测量冠状动脉病变部位及其参考部位的血管外弹力膜面积、管腔面积、斑块面积及管腔面积狭窄率,并计算斑块的偏心指数及血管重构指数.结果急性冠状动脉综合征患者中脂质斑块占77.8%(28/36),其中10例发生斑块破裂及血栓形成;稳定型心绞痛患者主要为纤维性斑块及混合性斑块,脂质斑块仅占10%(2/20),无斑块破裂及血栓形成.两组斑块的特征包括偏心性、外弹力膜面积、斑块面积及管腔面积狭窄率具有显著性差异.不稳定性斑块呈现明显的正性重构,占72.2%(26/36),而稳定性斑块主要表现为负性重构,占75%(15/20).结论血管内超声能够准确地识别动脉粥样硬化不稳定性斑块,为早期临床发现不稳定性斑块并预测斑块破裂奠定了基础.     

Angiographic evolution of coronary artery morphology in unstable angina

As previously reported in acute presentations of unstable angina, an identifiable characteristic coronary artery lesion has been found in about 70% of cases at coronary arteriography. This takes the form of an eccentrically placed convex stenosis with a narrow neck due to one or more overhanging edges or irregular, scalloped borders, or both. To study the evolution of lesions responsible for unstable angina, coronary artery anatomy and morphology on angiography were evaluated in patients with stable angina progressing to unstable angina. Group I comprised 25 patients with a history of stable angina who were restudied after an acute episode of unstable angina and Group II comprised 21 patients with little or no change in symptoms between catheterizations. Progression of coronary disease occurred in 19 (76%) of 25 patients in Group I compared with 7 (33%) of 21 in Group II (p less than 0.001). Of the 25 lesions with progression in Group I, 17 progressed to less than 100% and 8 to 100% occlusion. Eighteen of these 25 lesions in Group I were previously insignificant (less than 50% occlusion on the first catheterization). In contrast, of the eight lesions with disease progression in Group II, only two were previously insignificant while six showed at least 50% occlusion on the initial study. The eccentric lesion was seen in 71% of all lesions with progression to less than 100% occlusion in Group I, but it was not seen in any Group II vessel with progression.(ABSTRACT TRUNCATED AT 250 WORDS)     

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 angioscopy,intravascular ultrasound imaging and quantitative coronary angiography in predicting clinical outcome after coronary intervention in high risk patients

Objectives. The purpose of this study was to identify qualitative or quantitative variables present on angioscopy, intravascular ultrasound imaging or quantitative coronary arteriography that were associated with adverse clinical outcome after coronary intervention in high risk patients.Background. Patients with acute coronary syndromes and complex lesion morphology on angiography are at increased risk for acute complications after coronary angioplasty. Newer devices that primarily remove atheroma have not improved outcome over that of balloon angioplasty. Intravascular imaging can accurately identify intraluminal and intramural histopathologic features not adequately visualized during coronary arteriography and may provide mechanistic insight into the pathogenesis of abrupt closure and restenosis.Methods. Sixty high risk patients with unstable coronary syndromes and complex lesions on angiography underwent angioscopy (n = 40) and intravascular ultrasound imaging (n = 46) during interventional procedures. In 26 patients, both angioscopy and intravascular ultrasound were performed in the same lesion. All patients underwent off-line quantitative coronary arteriography. Coronary interventions included balloon (n = 21) and excimer laser (n = 4) angioplasty, directional (n = 19) and rotational (n = 6) atherectomy and stent implantation (n = 11). Patients were followed up for 1 year for objective evidence of recurrent ischemia.Results. Patients whose clinical presentation included rest angina or acute myocardial infarction or who received thrombolytic therapy within 24 h of procedure were significantly more likely to experience recurrent ischemia after intervention. Plaque rupture or thrombus on preprocedure angioscopy or angioscopic thrombus after intervention were also significantly associated with adverse outcome. Qualitative or quantitative variables on angiography, intravascular ultrasound of off-line quantitative arteriography were not associated with recurrent ischemia on univariate analysis. Multivariate predictors of recurrent ischemia were plaque rupture on preprocedure angioscopy (p < 0.05, odds ratio [OR] 10.15) and angioscopic thrombus after intervention (p < 0.05, OR 7.26).Conclusions. Angioscopic plaque rupture and thrombus were independently associated with adverse outcome in patients with complex lesions after interventional procedures. These features were not identified by either angiography or intravascular ultrasound.     

Elevation of C-reactive protein in "active" coronary artery disease

Unstable angina occurs most commonly in the setting of atherosclerotic coronary artery disease (CAD), but there is little information concerning the mechanisms responsible for the transition from clinically stable to unstable coronary atherosclerotic plaque. Recently, increased focal infiltration of inflammatory cells into the adventitia of coronary arteries of patients dying suddenly from CAD and activation of circulating neutrophils in patients with unstable angina have been observed. To characterize the presence of inflammation in "active" atherosclerotic lesions, the acute phase reactant C-reactive protein (CRP) was measured in 37 patients admitted to the coronary care unit with unstable angina, 30 patients admitted to the coronary care unit with nonischemic illnesses and 32 patients with stable CAD. CRP levels were significantly elevated (normal less than 0.6 mg/dl) in 90% of the unstable angina group compared to 20% of the coronary care unit group and 13% of the stable angina group. The average CRP values were significantly different (p = 0.001) for the unstable angina group (2.2 +/- 2.9 mg/dl) compared to the coronary care (0.9 +/- 0.7 mg/dl) and stable angina (0.7 +/- 0.2 mg/dl) groups. There was a trend for unstable angina patients with ischemic ST-T-wave abnormalities to have higher CRP values (2.6 +/- 3.4) than those without electrocardiographic changes (1.3 +/- 0.9, p = 0.1). The data demonstrate increased levels of an acute phase reactant in unstable angina. These findings suggest that an inflammatory component in "active" angina may contribute to the susceptibility of these patients to vasospasm and thrombosis.     

Unstable angina: from physiopathology to therapeutics]

Unstable angina is a term which encompasses several clinical syndromes (crescendo angina, angina de novo, resting angina, postinfarction angina), intermediary between stable angina and myocardial infarction. The results of coronary angioscopy have allowed differentiation of accelerated effort angina which seems related to ulceration of an atheromatous plaque from resting angina, more commonly associated with intraluminal thrombosis. The diagnosis of unstable angina is clinical and justifies immediate hospital admission to a coronary care unit because of the risk of myocardial infarction and/or sudden death. Medical management comprises triple anti-ischemic therapy (nitrate derivatives, betablockers, calcium antagonists), anticoagulants and platelet antiagregants. Randomised therapeutic trials versus placebo have shown that this treatment decreases the incidence of refractory angina and myocardial infarction. Several studies are under way to assess the role of thrombolytic therapy in unstable angina. When unstable angina is refractory to maximal medical therapy, emergency coronary angiography should be performed. However the outcome is usually favourable and coronary angiography can be performed several days after the acute event. The coronary lesion responsible for unstable angina is often "complex", an eccentric, irregular, severe stenosis or appearances of thrombosis. Whenever possible, depending on the coronary lesion, myocardial revascularisation by coronary angioplasty or aorto-coronary bypass should be proposed. Surgical treatment has been shown to be more effective (symptomatic relief, improved survival) than medical therapy in patients with triple vessel disease. However, the results of studies comparing medical or surgical treatment with coronary angioplasty are not yet available.     

Coronary stenoses and surgical possibilities according to the coronarographic indication. Evaluation of 1000 studies

The degree of severity of coronary artery lesions and the quality of the distal vessels which justify revascularisation by by-pass grafting were studied in 1,000 consecutive cases of coronary angiography. The results are presented in terms of the clinical indication for coronary angiography and in terms of the patients' age and sex. 47% of patients were investigated because of unstable angina and 53% of them had surgical lesions. 16% of the angiographies were performed three weeks after myocardial necrosis. 45% of these patients had a surgical lesion in a coronary territory other than that of the necrotic area. In 20% of cases, the coronary angiography was performed as part of the pre-operative work-up for valvular heart disease. 17% of these operations combined a by-pass graft with the valve replacement. Independent of the indication for coronary angiography, 20% of cases had major coronary artery stenoses which reduced the lumen by more than 70% and which were inoperable.