Skip to main content
SpringerLink
Log in
Book cover

Coronary Circulation and Myocardial Ischemia pp 90–98Cite as

Prognosis in Unstable Angina

  • Chapter

  • 94 Accesses

Part of the book series: Update in Intensive Care Medicine ((UICMSOFT,volume 32))

Abstract

Unstable angina has always encompassed a variety of conditions that have interfered with a linear evaluation of its natural course since patients with prolonged history of stable angina have been evaluated along with those of recent onset angina and those with prolonged angina and persistent ST-T wave changes [1–12]. Surprisingly enough, the tendency has been to enlarge the group with patients with a non-Q wave myocardial infarction which in itself includes also a rather broad spectrum of conditions such as a transmural posterior myocardial necrosis or an extensive subendocardial infarction [1, 2, 4–6, 12]. The reason for such a broad concept is the knowledge of a likely common underlying physiopathology [1, 2, 4–6, 12]. In fact, cases with either a recent onset angina at rest, a progressive stable angina or a prolonged angina, with or without enzyme elevation, appear to have in common a fractured plaque [13–16] with a thrombotic component of variable size, which causes a critical coronary stenosis or a temporary occlusion [1, 2, 4–6, 12]. Presumably, the determinants of the in-hospital course of these different presentations could be the same as those that may condition their initial follow-up after discharge. Nevertheless, the term “unstable” is still presiding this syndrome because of the uncertainty of the in-hospital course which may eventually lead to an infarction or a reinfarction, a cardiac death or to the need for in-hospital coronary revascularization.

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Dalen JE, Ockene IS, Alpert JS. Coronary spasm, coronary thrombosis and myocardial infarction: a hypothesis concerning the pathophysiology of acute myocardial infarction. Am Heart J 1982; 104: 1119–1124.

    Article  PubMed  CAS  Google Scholar 

  2. Mandelkorn JB, Wolf NM, Singh S, Schechter JA, Kersh RI, Rodgers DM, Workman MB, Bentivoglio LG, LaPorte SM, Meister SG. Intracoronary thrombi in nontransmural infarction and unstable angina. Am J Cardiol 1983; 52: 1–6.

    Article  PubMed  CAS  Google Scholar 

  3. Gohlke H, Samek L, Betz P, Roskam H. Exercise testing provides additional prognostic information in angiographically defined subgroups of patients with coronary artery disease. Circulation 1983; 68: 979–985.

    Article  PubMed  CAS  Google Scholar 

  4. Boden WE, Bough EW, Benham I, Shulman RS. Unstable angina with episodic ST segment elevation with minimal creatine kinase release culminating in extensive recurrent infarction. J Am Coll Cardiol 1983; 2: 11–20.

    Article  PubMed  CAS  Google Scholar 

  5. Ambrose JA, Hjemdahl-Monsen CE, Borrico S, Gorlin R, Fuster V. Angiographic demonstration of a common link between unstable angina pectoris and non-Q-wave myocardial infarction. Am J Cardiol 1988; 61: 244–247.

    Article  PubMed  CAS  Google Scholar 

  6. Schreiber TL, Macina G, McNulty A, Bunnell P, Kikel M, Miller DM, Devereux RB, Tenney R, Cowley M, Zola B. Urokinase plus heparin versus aspirin in unstable angina and non-Q-wave myocardial infarction. Am J Cardiol 1989; 64: 840–844.

    Article  PubMed  CAS  Google Scholar 

  7. Olson HG, Lyons KP, Aronow WS, Stinson PJ, Kuperus J, Waters HJ. The high-risk angina patient. Identification by clinical features, hospital course, electrocardiography and technetium-99 m stannous pyrophosphate scintigraphy. Circulation 1981; 64: 674–684.

    Article  PubMed  CAS  Google Scholar 

  8. Donsky MS, Curry GC, Parkey RW, Meyer SL, Bonte FJ, Platt MR, Willerson JT. Unstable angina pectoris. Clinical, angiographic and myocardial scintigraphic observations. Br Heart J 1976; 38: 257–263.

    Article  PubMed  CAS  Google Scholar 

  9. Jaffe AS, Klein MS, Patel BR, Siegel BA, Roberts R. Abnormal technetium-99 m pyrophosphate images in unstable angina: ischemia versus infarction? Am J Cardiol 1979 44: 1035–1039.

    Article  PubMed  CAS  Google Scholar 

  10. Poliner L, Buja LM, Parker RW, Bonte FJ, Willerson JT. Clinicopathologic findings in 52 patients studied by technetium-99 m stannaous-pyrophsphate myocardial scintigraphy. Circulation 1979; 59: 257–267.

    PubMed  CAS  Google Scholar 

  11. Guthrie RB, Vlodaver Z, Nicoloff DM, Edwards J. Pathology of stable and unstable angina pectoris. Circulation 1975; 51: 1059–1063.

    PubMed  CAS  Google Scholar 

  12. Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acutre coronary syndromes. N Engl J Med 1992;326:242–250.

    Article  PubMed  CAS  Google Scholar 

  13. Scanlon PJ, Nemickas R, Moran JF, Talano JV, Amirpirviz F, Pifarre R. Accelerated angina pectoris: clinical, hemodynamic, arteriographic and therapeutic experience in 85 patients. Circulation 1973; 47: 19–27.

    PubMed  CAS  Google Scholar 

  14. Ouyang P, Brinker JA, Mellits ED, Weisfeldt ML, Gerstenblith G. Variables predictive of successful medical therapy in patients with unstable angina: selection by multivariate analysis from cnical, electrocardiographic and angiographic evaluations. Circulation 1984; 70: 367–376.

    Article  PubMed  CAS  Google Scholar 

  15. Plotnick G, Conti CR. Unstable angina: angiography, morbidity and mortality of medically treated patients. Am J Med 1977; 63: 870–879.

    Article  PubMed  CAS  Google Scholar 

  16. Allison HV, Russell RO, Mantle JA, Kouchoukos N, Moraski RE, Rackley CE. Coronary anatomy and arteriography in patients with unstable angina pectoris. Am J Cardiol 1978; 204–209.

    Google Scholar 

  17. Fowler NO. “Pre-infarctional” angina. A need for an objective definition and for a controlled clinical trial of its management. Circulation 1971; 44:753–758.

    Google Scholar 

  18. Gazes PC, Mobley EM, Faris HM Jr, Duncan RC, Humphries GP. Preinfarction (unstable angina) — a prospective study — ten year follow-up. Prognostic significance of electrocardiographic changes. Circulation 1973; 48: 331–337.

    PubMed  CAS  Google Scholar 

  19. Krauss KR, Hutter AM Jr, DeSanctis RW. Acute coronary insufficiency. Course and follow-up. Arch Intern Med 1972;129:808–813.

    Article  PubMed  CAS  Google Scholar 

  20. Fulton M, Duncan B, Lutz W, Morrison SL, Donald KW, Kerr F, Kirby BJ, Julian DG. Natural history of unstable angina. Lancet 1972;1:860–865.

    Article  PubMed  CAS  Google Scholar 

  21. Mulcahy R, Awadhi A, Buitleor M, Tobin G, Johnson H, Contoy R. Natural history and prognosis of unstable angina. Am Heart J 1985; 109: 753–758.

    Article  PubMed  CAS  Google Scholar 

  22. Russell RO Jr, Moraski RE, Kouchoukos N and the Unstable angina pectoris Study Group. Unstable angina pectoris: National Cooperative Study group to compare surgical and medical therapy. II. In-hospital experience and initial follow-up results in patients with one, two, and three vessel disease. Am J Cardiol 1978; 42: 839–848.

    Article  Google Scholar 

  23. Duncan B, Fulton M, Morrison SL, Lutz W, Donald KW, Kerr F, Kirby BJ, Julian DG, Oliver MF. Prognosis of new and worsening angina pectoris. Br Med J 1976;1:981–985

    Article  PubMed  CAS  Google Scholar 

  24. Langer A, Freeman MR, Armstrong PW. ST segment shift in unstable angina: Pathophysiology and association with coronary anatomy and hospital outcome. J Am Coll Cardiol 1989; 13:1495–1502.

    Article  PubMed  CAS  Google Scholar 

  25. Gottlieb SO, Weisfeldt MLK, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcome in patients with unstable angina. N Engl J Med 1986; 314: 1214–1219.

    Article  PubMed  CAS  Google Scholar 

  26. Lewis HD, Davis JW, Archibald DG, Steinke WE, Smitherman TC, Doherty JE, Schnaper HW, LeWinter MM, Linares E, Pouget JM, Sabharwal SC, Chesler E, DeMots H. Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. N Engl J Med 1983;309:396–403.

    Article  PubMed  Google Scholar 

  27. Heng MK, Norris RM, Singh BN, Partridge JB. Prognosis in unstable angina. Br Heart J 1976; 38:921–925.

    Article  PubMed  CAS  Google Scholar 

  28. Mulcahy R, Daly L, Graham I, Hickey N, O’Donoghue S, Owens A, Ruane P, Tobin G. Unstable angina. Natural history and determinants of prognosis. Am J Cardiol 1981; 48:525–528.

    Article  PubMed  CAS  Google Scholar 

  29. Theroux P, Ouimet H, McCans J, Latour JG, Joly P, Levy G. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med 1988; 319:1105–1111.

    Article  PubMed  CAS  Google Scholar 

  30. Figueras J, Lidon RM. Coronary reserve, extent of coronary disease, recurrent angina and ECG changes during pain in the in-hospital prognosis of acute coronary syndromes. Eur Heart J 1993;14:185–194.

    Article  PubMed  CAS  Google Scholar 

  31. The Timi IIIb Investigators. Effects of Tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIb trial. Circulation 1994;89;1545–1556.

    Google Scholar 

  32. Fragmin during instability in Coronary Artery Disease (FRISC) study group. Low-molecular-weight heparin during instability in coronary artery disease. Lancet 1996;347:561–568.

    Google Scholar 

  33. Figueras J, Cinca J, Valle V, Rius J. Prognostic implications of early spontaneous angina after acute transmural myocardial infarction. Int J Cardiol 1983;4:261–272.

    Article  PubMed  CAS  Google Scholar 

  34. Bugiardini R, Pozzati A, Borghi A, Morgagni JL, Ottani F, Muzi A, Puddu P. Angiographic morphology in unstable angina and its relation to transient myocardial ischemia and hospital outcome. Am J Cardiol 1991;67:460–464.

    Article  PubMed  CAS  Google Scholar 

  35. Bertolet BD, Dinerman J, Hartke R Jr, Conti CR. Unstable angina. Relationship of clinical presentation, coronary artery pathology, and clinical outcome. Clin Cardiol 1993;16:116–122.

    Article  PubMed  CAS  Google Scholar 

  36. The Global Use of Strategies to open occluded coronary arteries (GUSTOIIb) Investigators. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. N Engl J Med 1996;335:775–782.

    Article  Google Scholar 

  37. Sclarovsky S, Davidson E, Lewin RF, Strasberg B, Arditti A, Agmon J. Unstable angina pectoris evolving to acute myocardial infarction: significance of ECG changes during chest pain. Am Heart J 1986; 112: 459–462.

    Article  PubMed  CAS  Google Scholar 

  38. Holdright DR, Patel D, Cunningham D, Thomas R, Hubbard W, Hendry G, Sutton G, Fox K. Comparison of the effects of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in-hospital prognosis in patients with unstable angina. J Am Coll Cardiol 1994;24:39–45.

    Article  PubMed  CAS  Google Scholar 

  39. Organization to assess strategies for ischemic syndromes (OASIS) investigators. Comparison of the effect of two doses of recombinant hirudin compared with heparin in patients with acute myocardial ischemia without ST elevation. Circulation 1997;96:769–777.

    Google Scholar 

  40. Klein W, Buchwald A, Hillis SE, Mionrad S, Sanz G, Turpie GG, Van der Meer J, Olaisson E, Undeland S, Ludwig K. For the FRIG investigators. Comparison of low-molecular-weight heparin with unfractionated heparin acutely and with placebo for 6 weeks in the management of unstable coronary artery disease. Fragmin in unstable coronary artery disease study (FRIC). Circulation 1997;96:61–68.

    PubMed  CAS  Google Scholar 

  41. Cohen M, Demers C, Gurfinkel E, Turpie A, Fromell GJ, Langer A, Califf RM, Fox KAA, Premmereur J, Bigonzi F (Essence) A comparison of low molecular weight heparin with un fractionated heparin for unstable coronary artery disease. Efficacy and safety of subcutaneous enoxaparine in non Q-wave coronary events Studty Group, N Engl Jmed 1997;337:447–452.

    Article  CAS  Google Scholar 

  42. Balsano F, Rizzon P, Violi F, Scrutinio D, Cimminiello C, Aguglia F. Antiplatelet treatment with ticlopidine in unstable angina. A controlled multicenter clinical trial. Circulation 1990;82: 17–26.

    Article  PubMed  CAS  Google Scholar 

  43. Papapietro SE, Niess GS, Paine TD, Mantle JA, Rackley CE, Russell RO Jr, Rogers WJ. Transient electrocardiographic changes in patients with unstable angina: relation to coronary arterial anatomy. Am J Cardiol 1980; 46: 28–33.

    Article  PubMed  CAS  Google Scholar 

  44. DeServi S, Ghio S, Ferrario M, Ardissino D, Angoli L, Mussini A, Bramucci E, Salerno V, Vigano M, Montemartini C, Specchia G. Clinical and angiographic findings in angina at rest. Am Heart J 1986; 111:6–11.

    Article  CAS  Google Scholar 

  45. Plotnick GD. Unstable angina. A clinical approah. Futura Pub. Comp. Inco. New York, 1985, 191–199.

    Google Scholar 

  46. Nadamanee K, Intarachit V, Josephson MA, Rieders D, Vaghaiwalla F, Singh BN. Prognostic significance of silent myocardial ischemia in patients with unstable angina. J Am Coll Cardiol 1987; 10: 1–9.

    Article  Google Scholar 

  47. Armstrong PW, Chiong MA, Parker JO. The spectrum of unstable angina: Prognostic role of serum creatine kinase determination. Am J Cardiol 1982; 49: 1849–1852.

    Article  PubMed  CAS  Google Scholar 

  48. Hamm CW, Ravkilde J, Gerhaardt W, Jorgensen P, Peheim E, Ljungdahl L, Goldmann B, Katys HA. The prognostic value of serum troponin T in unstable angina. N Engl J Med 1992:327;146–150.

    Article  PubMed  CAS  Google Scholar 

  49. Nixon JV, Hillert MC, Shapiro W, Smitherman T. Submaximal exercise testing after unstable angina. Am Heart J 1980; 99:772–778.

    Article  PubMed  CAS  Google Scholar 

  50. Butman SM, Olson HG, Gradin JM, Piters KM, Hullet M, Butman LK. Submaximal exercise testing after ustabilization of unstable angina pectoris. J Am Coll Cardiol 1984; 4:667–673.

    Article  PubMed  CAS  Google Scholar 

  51. Swahn E, Areskog M, Berglund U, Walfridsson H, Wallentin L. Predictive importance of clinical findings and a predischarge exercise test in patients with suspected unstable coronary artery disease. Am J Cardiol 1987; 59: 208–214.

    Article  PubMed  CAS  Google Scholar 

  52. Scott SM, Luchi RJ, Deupree RH. Veterans Administration Cooperative Study for treatment of patients with unstable angina. Results in patients with abnormal left ventricular function. Circulation 1988;78:supp I:I:113–121.

    Google Scholar 

  53. Nyman I, Wallentin L, Areskpog M, Areskog NH, Swahn E. RISC study group. Risk stratification by early exercise testing after an episode of unstable coronary artery disease. In J Cardiol 1993;39:131–142.

    CAS  Google Scholar 

  54. Marmur JD, Freeman MR, Laanger A, Armstrong PW. Prognosis in medically stabilized unstable angina. Early Holter ST-segment monitoring compared with predischarge thallium tomography. Ann Intern Med 1990;113:575–578.

    PubMed  CAS  Google Scholar 

  55. Brown KA. Prognostic value of thallium-201 myocadrial perfusion imaging in patients with unstable angina who respond to medical treatment. J Am Coll Cardiol 1991;17:1053–1057.

    Article  PubMed  CAS  Google Scholar 

  56. Romeo F, Rosano GMC, Martuscelli E, Vaalente A, Reale A Unstable angina: role of silent ischemia and total ischemic time (silent plus painful ischemia), a 6 year follow-up. J Am Coll Cardiol 1992;19;1173–1179.

    Article  PubMed  CAS  Google Scholar 

  57. Patel DJ, Holdright DR, Knight CJ, Mulcahy D, Thakrar B, Wright C, Sparrow J, Wicks M, Hubbard W, Thomas R, Sutton GC, Hendry G, Purcell H, Fox K. Early continuous ST segment monitoring in unstable angina: prognostic value additional to the clinical characteristics and the admission electrocardiogram. Heart 1996;75:222–228.

    Article  PubMed  CAS  Google Scholar 

  58. Bugiardini R, Borghi A, Pozzati A, Ruggeri A, Puddu P, Maseri A. Relation of severity of symptoms to transient myocartdial ischemia and prognosis in unstable angina. J Am Coll Cardiol 1995;25:597–604.

    Article  PubMed  CAS  Google Scholar 

  59. Holmvang L, Lüscher MS, Clemensen P, Thygesen K, Graande P,. Very early stratification using combined ECG and biochemical assessment in partients with unstable coronary artery disease (A thrombin inhibition in Myocardial ischemia (TRIM) substudy. Circulation 1998;98:2004–2009.

    PubMed  CAS  Google Scholar 

  60. Bär FW, Raynaud P, Renkin JP, Vermeer F, De Zwaan C, Wellens HJJ. Coronary arteriographic findings do not predict clinical outcome in patients with unstable angina. J Am Coll Cardiol 1994;24:1453–1459.

    Article  PubMed  Google Scholar 

  61. Maise AS, Ahrve S, Gilpin E, Henning H, Goldberger AL, Collins D, LeWinter M, Ross J Jr. Prognosis after extension of myocardial infarction: the role of Q wave and non-Q-wave infarction. Circulation 1985; 71: 211–217.

    Article  Google Scholar 

  62. Gibson RS, Beller GA, Gheorghiades M, Nygaard TW, Watson DD, Huey BL, Sayre SL, Kaiser DL. The prevalence and clinical significance of residual myocardial ischemia 2 weeks after uncomplicated non-Q-wave infarction: a prospective natural history study. Circulation 1986; 73:1186–1198.

    Article  PubMed  CAS  Google Scholar 

  63. Stratman HG, Tamesis BR, Youni LT, Wittry MD, Amato M, Miller DD. Prognostic value of predischarge dipyridamole technetium 99 m sestamibi myocardial tomography in medically treated patients with unstable angina. Am Heart J 1995:130:734740.

    Article  Google Scholar 

  64. Kent KM, Rosing DR, Ewels CJ, Lipson L, Bonow R, Epstein SE. Prognosis of asymptomatic or mildly symptomatic patients with coronary artery disease. Am J Cardiol 1982; 49: 1823–1830.

    Article  PubMed  CAS  Google Scholar 

  65. Weiner DA, Ryan TJ, McCabe CH, Chaitman BR, Sheffield LT, Ferguson JC, Fisher LD, Tristan F. Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984; 3: 772–779.

    Article  PubMed  CAS  Google Scholar 

  66. Zalewski A, Shi Y, Nardone D, Bravettee B, Weinstock P, Fischman D, Wilson P, Goldberg S, Levin DC, Bjornsson TD. Evidence for reduced fibrinolytic activity in unstable angina at rest. Clinical, biochemical, and angiographic correlates. Circulation 1991;83:1685–1691.

    PubMed  CAS  Google Scholar 

  67. Munkvad S, Gram J, Jespersen J. A depression of active tissue plasminogen activator in plasma characterizes patients with unstable angina pectoris who develop myocardial infarction. Eur Heart J 1990;11:525–528.

    PubMed  CAS  Google Scholar 

  68. Liuzzo G, Biasucci LM, Gallimore RJ, Grillo RL, Rebuzzi AG, Pepys MB, Maseri A. The prognostic value of C-reactive protein and serum amyloyd A protein in severe unstable angina. N Engl J Med 1994;331:417–24.

    Article  PubMed  CAS  Google Scholar 

  69. Morrow DA, Rifai N, Antman EM, Weiner DL, McCabe CH, Cannon CP, Braunwald E. C-Reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: A TIMI 11 substudy. J Am Coll Cardiol 1998; 31:1460–1465.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Coronary Care Unit, Hospital Vall d’Hebron, Barcelona, Spain

    J. Figueras

Authors
  1. J. Figueras
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    Michael R. Pinsky MD, CM, FCCP, FCCM (Director of Research Division of Critical Care Medicine Professor of Anesthesiology and Critical Care Medicine) (Director of Research Division of Critical Care Medicine Professor of Anesthesiology and Critical Care Medicine)

  2. Department of Cell Biology and Physiology, Autonomous University, Barcelona, Spain

    Antonio Artigas MD, PhD (Director of Critical Care Center Sabadell Hospital Associate Professor) (Director of Critical Care Center Sabadell Hospital Associate Professor)

  3. Paris, France

    Jean-Francois Dhainaut MD, PhD (Director of Medical Intensive Care Unit Dean of Cochin Port-Royal Medical School Vice-President of Paris University) (Director of Medical Intensive Care Unit Dean of Cochin Port-Royal Medical School Vice-President of Paris University)

Rights and permissions

Reprints and permissions

Copyright information

© 2002 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Figueras, J. (2002). Prognosis in Unstable Angina. In: Pinsky, M.R., Artigas, A., Dhainaut, JF. (eds) Coronary Circulation and Myocardial Ischemia. Update in Intensive Care Medicine, vol 32. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-57212-8_8

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-57212-8_8

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-540-42588-5

  • Online ISBN: 978-3-642-57212-8

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation