NOVELTIES IN GUIDELINES FOR MANAGEMENT OF UNSTABLE ANGINA PECTORIS
Abstract
Background. Unstable angina pectoris is together with non-transmural or non-Q myocardial infarction, being recently known as non-ST-elevation myocardial infarction, one of the most unpredictible forms of acute coronary syndrome. In majority of cases the patoanatomical substratum is considered acute rupture of an atherosclerotic plaque inducing the cascade of pathological processes including acute arterial thrombosis and spasm with consequent critical reduction of local coronary flow.
First clinically useful and generally accepted classification of unstable angina pectoris was proposed by Braunwald in 1989. It was completed by him and a group of experts of the Ministry of Health in 1994, when criteria for the classification according to the degree of risk were added. They were of high practical value in decision making for early invasive or for conservative treatment. He considered early invasive approach medically and economically justified only in high risk group, it is in about 25% of patients admitted as unstable angina pectoris.
Some prospective randomized trials being conducted later without of use of troponine test as a measure of risk, without of coronary stents and of glycoproteine IIb/IIIa receptor inhibitors, were not able to demonstrate any reliable advantage of early invasive (first 6 to 48 hours) in respect to conservative approach. Most recent studies well using these three novel methods demonstrated significantly better effects of early invasive approach in high risk group and even in those moderate risk patients having positive troponin test or obvious ischemia on exercise.They represent about 50% of all admitted as unstable angina pectoris.
Conclusions. Considering current international standards of diagnostics, of invasive and conservative treatment in unstable angina pectoris/non-ST-elevation myocardial infarction and taking into account the latest findings of prospective randomised trials we feel obliged to early invasive approach in all high risk and in many among moderate risk patients.
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