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Tang Y, Cai H, Zhan Z, Luo Y, Huang Y, Chen D, Chen B. Herbal medicine (zhishi xiebai guizhi decoction) for unstable angina: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e13965. [PMID: 30593220 PMCID: PMC6314720 DOI: 10.1097/md.0000000000013965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 12/11/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unstable angina (UA) is a clinically common coronary heart disease. Zhishi xiebai guizhi decoction (ZXGD) has been widely used in the management of UA, although its effective evidence is not clear and there is no systematic review regarding its efficacy and safety. Therefore, we conduct this systematic review protocol to evaluate the efficacy and safety of ZXGD in the treatment of UA. METHODS We will search the following electronic databases: Cochrane Library, Web of Science, PubMed, EBASE, Springer, WHO International Clinical Trial Registration Platform, China Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Scientific Journal Database (VIP), and Wan-fang database from their inception to October 2018. Only randomized controlled trials (RCTs) published in English and Chinese will be included. Continuous data will be expressed as mean difference or standard mean difference, and dichotomous data relative as risk. Study selection, data extraction, and assessment with risk of bias and data analysis will be performed by two independent authors. RevMan software version 5.3 will be used for meta-analysis. RESULTS This study will provide high-quality evidence of ZXGD in the treatment of UA from the following aspects, including clinical efficacy, blood lipids, Seattle angina scale, electrocardiogram improvement, ST-segment depression, left ventricular ejection fraction, angina duration, and adverse events. CONCLUSION This systematic review will provide a basis for judging whether ZXGD is an effective intervention for UA or not. PROSPERO REGISTRATION NUMBER PROSPERO CRD 42018115528.
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Affiliation(s)
- Yong Tang
- Department of Internal medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine
- The Third Clinical Medical College
| | - Hairong Cai
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine
| | - Zhenye Zhan
- Department of Emergency, Panyu District Central Hospital of Guangzhou
| | - Yajie Luo
- Department of Emergency, Panyu District Central Hospital of Guangzhou
| | - Yonglian Huang
- Department of Critical Care Medicine, Shenzhen Hospital of Beijing University of Chinese Medicine, Shenzhen
| | - Dongjie Chen
- Department of Critical Care Medicine, Shenzhen Hospital of Beijing University of Chinese Medicine, Shenzhen
| | - Bojun Chen
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine
- Department of Emergency, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
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Aronow WS. Antiplatelet Drug Use in Patients with Non-ST-Segment Elevation Acute Coronary Syndromes. Postgrad Med 2015; 125:51-8. [PMID: 23391671 DOI: 10.3810/pgm.2013.01.2624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Farkouh ME, Aneja A, Reeder GS, Smars PA, Bansilal S, Lennon RJ, Wiste HJ, Razzouk L, Traverse K, Holmes DR, Mathew V. Clinical risk stratification in the emergency department predicts long-term cardiovascular outcomes in a population-based cohort presenting with acute chest pain: primary results of the Olmsted county chest pain study. Medicine (Baltimore) 2009; 88:307-313. [PMID: 19745690 PMCID: PMC3845366 DOI: 10.1097/md.0b013e3181b98782] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all EDs in Olmsted County, Minnesota. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. Patients with ST elevation myocardial infarction and chest pain of noncardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and at a median follow-up of 7.3 years, and mortality through a median of 16.6 years.The 2271 patients were classified as follows: 436 (19.2%) as high risk, 1557 (68.6%) as intermediate risk, and 278 (12.2%) as low risk. Thirty-day MACCE occurred in 11.5% in the high-risk group, 6.2% in the intermediate-risk group, and 2.5% in the low-risk group (p < 0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate-risk (hazard ratio [HR], 1.91; 95% confidence intervals [CI], 1.33-2.75) and high-risk groups (HR, 2.45; 95% CI, 1.67-3.58). Intermediate- and high-risk patients demonstrated a 1.38-fold (95% CI, 0.95-2.01; p = 0.09) and a 1.68-fold (95% CI, 1.13-2.50; p = 0.011) higher mortality, respectively, compared to low-risk patients at 16.6 years. At 7.3 and at 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk.In conclusion, a widely applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from a more aggressive cardiovascular risk factor management strategy.
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Affiliation(s)
- Michael E Farkouh
- From Division of Cardiovascular Diseases and Internal Medicine (GSR, DRH, VM), Division of Emergency Medical Services and Internal Medicine (PAS), Division of Biomedical Statistics and Informatics (RJL, HJW), and Section of Health Services Evaluation (KT), Mayo Clinic College of Medicine, Mayo Clinic and Foundation, Rochester, Minnesota; and Mount Sinai School of Medicine Cardiovascular Institute (MEF, AA, SB, LR), New York, New York
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García-Dorado D, Permanyer-Miralda G, Brotons C, Calvo F, Campreciós M, Oliveras J, Santos MT, Moral I, Soler-Soler J. Attenuated severity of new acute ischemic events in patients with previous coronary heart disease receiving long-acting nitrates. Clin Cardiol 2009; 22:303-8. [PMID: 10198741 PMCID: PMC6655313 DOI: 10.1002/clc.4960220410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Platelet aggregation and secondary vasoconstriction are key events in the genesis of acute coronary syndromes. HYPOTHESIS Since nitrates have vasodilatory and antiaggregant effects, treatment with long-acting nitrates at the time of onset of acute coronary syndromes could be associated with attenuation of their severity. METHODS A consecutive series of 533 patients with acute coronary syndrome and past history of coronary artery disease admitted to the Cardiology Service of a general hospital was studied. A specific questionnaire assessed the use of nitrates and other relevant drugs, as well as other clinical variables. The diagnosis of unstable angina or acute myocardial infarction (MI) was established according to clinical, electrocardiographic, and enzymatic criteria. RESULTS In the whole cohort, 169 patients had MI and 364 had unstable angina. Previous use of long-acting nitrates was significantly more common in patients with unstable angina (56%) than in those with MI (37%) (p < 0.0001). Multivariate analysis identified being a nonsmoker [odds ratio: 95%, confidence limits (CL) 0.37, 0.23-0.59], previous unstable angina (CL 0.62, 0.41-0.92), use of aspirin (CL 0.58, 0.41-0.92), and use of long-acting nitrates (CL 0.61, 0.40-0.93) as the independent predictors of the development of unstable angina rather than MI; of these the combination of nitrates and aspirin was the strongest predictor. CONCLUSIONS Long-acting nitrates as well as aspirin are suggested to have a protective or modifying effect on the development of acute coronary syndromes, favoring unstable angina rather than acute MI.
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Affiliation(s)
- D García-Dorado
- Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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Bednarz B, Wolk R, Mazurek T, Stec S, Chamiec T. Event-free survival in patients after an acute coronary event with exercise-induced normalization of the T-wave. Clin Cardiol 2009; 24:564-9. [PMID: 11501609 PMCID: PMC6654879 DOI: 10.1002/clc.4960240808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Risk stratification of patients with unstable angina or non-Q-wave myocardial infarction (MI) is an unresolved clinical problem. The prognostic value of T-wave normalization (TWN) during exercise has not been studied in this group of patients. HYPOTHESIS Event-free survival in clinically stable patients after an acute coronary event without ST-segment elevation can be predicted by the presence of exercise-induced TWN. METHODS Sixty-five patients (43 men and 22 women, mean age 62+/-10 years) entered the study. The diagnosis of unstable angina and non-Q-wave MI was made in 40 and 25 patients, respectively. A treadmill exercise test was performed in all patients after clinical stabilization. The patients were divided into three groups: those with negative baseline T waves and exercise-induced TWN (Group 1); those with negative baseline T waves, but without TWN (Group 2); and those with positive baseline T waves (Group 3). The patients were followed up for 6 months. RESULTS During follow-up, serious cardiovascular complications occurred in 15 (23%) patients. These included exacerbation of ischemic heart disease (14 patients) and acute MI (1 patient). Event-free survival was greater in patients in Group 1 (95%) than in those in Group 2 (68%, p < 0.034) or Group 3 (71%, NS). Among all patients studied, exercise-induced TWN was predictive of event-free survival with a sensitivity of 38% and a specificity of 93%. CONCLUSIONS In clinically stable patients after an acute coronary event without ST-segment elevation, exercise-induced TWN is a specific but n ot sensitive predictor of event-free survival after 6 months.
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Affiliation(s)
- B Bednarz
- Department of Cardiology, Postgraduate Medical School, Warsaw, Poland
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Abstract
The mainstay of treatment for unstable coronary artery disease (UCAD) currently consists of antithrombotic therapy with aspirin plus unfractionated heparin (UFH), together with anti-ischemic treatment with beta blockers and nitrates. Recently, there has been a trend toward replacement of UFH with low-molecular-weight heparins (LMWHs), since these products offer significant advantages over the parent compound. Several lines of evidence suggest that prolongation of treatment with LMWHs beyond the acute phase may be appropriate in patients with UCAD. The Fragmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) study was designed to evaluate this hypothesis using the LMWH dalteparin sodium (Fragmin). A factorial design was used to randomize patients enrolled in the FRISC II study to an invasive or noninvasive management strategy, and to treatment with dalteparin sodium or placebo. Treatment with dalteparin sodium significantly reduced incidences of death and/or myocardial infarction (MI) during the first months of treatment (the reduction in the relative risk of double endpoint events was statistically significant at 47.0% at 1 month, and remained so at 2 months, but was no longer statistically significant at the 3-month assessment). However, risk, as defined by the triple endpoint of death, MI, and revascularization, was significantly lower (13.0% relative risk reduction) at 3-month follow-up in the treatment group randomized to dalteparin sodium than among patients receiving placebo. In patients in whom revascularization procedures were carried out, the risk of new, postprocedural events was low in both the placebo and dalteparin sodium arms. Thus, dalteparin sodium appears to protect patients from cardiac events until they undergo invasive procedures, and it can therefore be used as a bridge to revascularization.
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Affiliation(s)
- L Wallentin
- Department of Cardiology, University Hospital, Uppsala, Sweden.
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Murphy RT, Foley JB, Tome MT, Mulvihill NT, Murphy A, McCarroll N, Crean P, Walsh MJ. Vitamin E modulation of C-reactive protein in smokers with acute coronary syndromes. Free Radic Biol Med 2004; 36:959-65. [PMID: 15059636 DOI: 10.1016/j.freeradbiomed.2004.01.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2003] [Revised: 09/10/2003] [Accepted: 01/23/2004] [Indexed: 11/20/2022]
Abstract
Acute coronary syndromes are characterized by the expression of proinflammatory cytokines such as C-reactive protein (CRP). Sustained upregulation of inflammatory markers is associated with an adverse prognosis. Vitamin E is known to have significant anti-inflammatory properties and has been associated with a reduction in cardiovascular events in some studies of high-risk patients. The mechanism of benefit remains controversial. We conducted a randomized, double-blind placebo controlled trial of vitamin E 400 IU daily for 6 months in 110 patients with acute coronary syndromes. Serum samples were collected at enrollment and at 2, 4, and 6 months. CRP, interleukin-6 and the soluble cell adhesion molecules were measured. Vitamin E levels increased significantly in the treatment group (from 31 micromol/l at baseline to 51 micromol/l, p <.0001) and were unchanged in the placebo group (32 micromol/l at baseline to 34 micromol/l, p = NS). CRP levels fell in both the vitamin E group and the placebo group over the treatment period (from 17.2 +/- 2.9 to 6.1 +/- 0.8 mg/l and from 21.5 +/- 4.9 to 5.9 +/- 0.9 mg/l, p = NS for the difference between active and placebo groups). However, vitamin E treatment was associated with significantly lower 6 month CRP levels in smokers versus smokers on placebo (4.7 +/- 0.71 mg/l vs. 8.26 +/- 1.5 mg/l, p =.02). Vitamin E reduces CRP levels in smokers with acute coronary syndromes for up to 6 months after hospitalization.
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Affiliation(s)
- Ross T Murphy
- Department of Cardiology, St. James's Hospital, Dublin, Ireland.
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Abstract
This article reviews the epidemiology of comorbid coronary artery disease and unipolar depression. Both major depression and subsyndromal depressive symptoms will be considered; unless otherwise specified, the term depression will be used to designate all depressive states, including major depressive disorder, minor depression, dysthymia, and other subsyndromal forms of depression. While 17% to 27% of patients with coronary artery disease have major depression, a significantly larger percentage has subsyndromal symptoms of depression. Patients with coronary artery disease and depression have a twofold to threefold increased risk of future cardiac events compared to patients without depression, independent of baseline cardiac dysfunction. The relative risk for the development of coronary artery disease conferred by depression in patients initially free of clinical cardiac disease is approximately 1.5, independent of other known risk factors for coronary disease. In the discussion, special attention will be paid to the interactions of both gender and age with depression and coronary artery disease risk. Scrutiny of the role of confounding risk factors is presented, such as global burden of comorbid medical illness and modification of traditional risk factors, which may, in part, mediate the effect of depression on coronary artery disease.
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Affiliation(s)
- Bruce Rudisch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Affiliation(s)
- J J Goy
- Department of Cardiology, University Hospital, Lausanne, Switzerland
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Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998; 339:1349-57. [PMID: 9841303 DOI: 10.1056/nejm199811053391902] [Citation(s) in RCA: 3693] [Impact Index Per Article: 142.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with coronary heart disease and a broad range of cholesterol levels, cholesterol-lowering therapy reduces the risk of coronary events, but the effects on mortality from coronary heart disease and overall mortality have remained uncertain. METHODS In a double-blind, randomized trial, we compared the effects of pravastatin (40 mg daily) with those of a placebo over a mean follow-up period of 6.1 years in 9014 patients who were 31 to 75 years of age. The patients had a history of myocardial infarction or hospitalization for unstable angina and initial plasma total cholesterol levels of 155 to 271 mg per deciliter. Both groups received advice on following a cholesterol-lowering diet. The primary study outcome was mortality from coronary heart disease. RESULTS Death from coronary heart disease occurred in 8.3 percent of the patients in the placebo group and 6.4 percent of those in the pravastatin group, a relative reduction in risk of 24 percent (95 percent confidence interval, 12 to 35 percent; P<0.001). Overall mortality was 14.1 percent in the placebo group and 11.0 percent in the pravastatin group (relative reduction in risk, 22 percent; 95 percent confidence interval, 13 to 31 percent; P<0.001). The incidence of all cardiovascular outcomes was consistently lower among patients assigned to receive pravastatin; these outcomes included myocardial infarction (reduction in risk, 29 percent; P<0.001), death from coronary heart disease or nonfatal myocardial infarction (a 24 percent reduction in risk, P<0.001), stroke (a 19 percent reduction in risk, P=0.048), and coronary revascularization (a 20 percent reduction in risk, P<0.001). The effects of treatment were similar for all predefined subgroups. There were no clinically significant adverse effects of treatment with pravastatin. CONCLUSIONS Pravastatin therapy reduced mortality from coronary heart disease and overall mortality, as compared with the rates in the placebo group, as well as the incidence of all prespecified cardiovascular events in patients with a history of myocardial infarction or unstable angina who had a broad range of initial cholesterol levels.
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Abstract
There is a pressing need for improved diagnosis and treatment of unstable coronary artery disease (UCAD). The limitations of the 12-lead electrocardiogram for diagnosing the disease are outlined in this article and additional diagnostic methods are discussed. Available treatments for UCAD are reviewed, including coronary bypass surgery, coronary angioplasty, and medical therapy. Finally, the issue of optimizing healthcare resources is discussed. It is concluded that preventing atheroma from entering an unstable phase may be the most cost-effective way of managing UCAD.
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Affiliation(s)
- D P de Bono
- Department of Medicine, University of Leicester, United Kingdom
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Rozenman Y, Gilon D, Zelingher J, Sapoznikov D, Lotan C, Mosseri M, Weiss AT, Hasin Y, Gotsman MS. Importance of delaying balloon angioplasty in patients with unstable angina pectoris. Clin Cardiol 1996; 19:111-4. [PMID: 8821420 DOI: 10.1002/clc.4960190208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Angioplasty in patients with unstable coronary artery disease is associated with higher complication rates compared with patients with stable disease. In this report we describe our results from a group of patients with unstable disease (unstable angina pectoris and postmyocardial infarction) where a strategy of delaying angioplasty for > 5 days after admission was undertaken. Included are 2069 consecutive patients: 1197 treated for stable angina pectoris and 872 treated during admission for unstable angina or myocardial infarction. There was no difference between the two groups in angioplasty success (92.1% stable, 92.3% unstable), failure to dilate without complication (6.4% stable, 6.1% unstable), or in the rate of major complications: death (0.5% stable, 1.1% unstable), Q-wave myocardial infarction (0.9% stable, 1.1% unstable), and emergency coronary artery bypass (0.6% stable, 0.3% unstable). The duration of hospitalization following angioplasty was longer in the unstable group (5.6 +/- 8.1 days vs. 4.2 +/- 4.1 days; p < 0.001) because of longer duration of heparin infusion. There was no difference between groups in minor complications such as groin hematoma and pseudoaneurysm, renal failure, or infections. It was concluded that delaying angioplasty in unstable patients for > 5 days after admission is a safe and effective therapeutic strategy for this group of patients. The need for prolonged heparin infusion after angioplasty is increased in unstable patients and thus the duration of hospitalization after the procedure is longer.
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Affiliation(s)
- Y Rozenman
- Cardiology Department, Hadassah University Hospital, Jerusalem, Israel
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Anderson HV, Cannon CP, Stone PH, Williams DO, McCabe CH, Knatterud GL, Thompson B, Willerson JT, Braunwald E. One-year results of the Thrombolysis in Myocardial Infarction (TIMI) IIIB clinical trial. A randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-Q wave myocardial infarction. J Am Coll Cardiol 1995; 26:1643-50. [PMID: 7594098 DOI: 10.1016/0735-1097(95)00404-1] [Citation(s) in RCA: 209] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We report mortality, infarction, revascularization and repeat hospital admission events for 1 year after enrollment and randomization in the Thrombolysis in Myocardial Ischemia (TIMI) IIIB clinical trial. BACKGROUND The purpose of this trial was to investigate the role of a thrombolytic agent added to conventional medical therapies and to compare an early invasive management strategy to a more conservative early strategy in patients with unstable angina and non-Q wave myocardial infarction. METHODS There were 1,473 patients enrolled, and they received conventional anti-ischemic medical therapies. They were randomized to therapy with either tissue-type plasminogen activator (t-PA) or placebo and also to an early invasive management strategy with coronary arteriography at 18 to 48 h, followed by revascularization as soon as possible if appropriate, or, alternatively, to an early conservative strategy with arteriography and revascularization reserved for failure of initial therapy to prevent recurrent ischemia. The primary end point was a composite outcome variable and was assessed at 42 days. Patients were then managed entirely at the discretion of their treating physician. Follow-up contacts were made at 1 year. RESULTS The incidence of death or nonfatal infarction for the t-PA- and placebo-treated groups was similar after 1 year (12.4% vs. 10.6%, p = 0.24). The incidence of death or nonfatal infarction was also similar after 1 year for the early invasive and early conservative strategies (10.8% vs. 12.2%, p = 0.42). A trial of this size should be able to detect differences in relative risk for death or infarction > or = 1.81 with a power of 80% at a significance level (alpha) of 0.01. Revascularization by 1 year was common, but was slightly more common with the early invasive than the early conservative strategy (64% vs. 58%, p < 0.001). This result was related entirely to a small difference in angioplasty rates (39% vs. 32%, p < 0.001) inasmuch as rates of bypass grafting by 1 year were equivalent (30% in each group, p = 0.50). The high rate of revascularization in both strategies was accompanied by comparable clinical status at the 1-year follow-up contact. CONCLUSIONS In this large study of unstable angina and non-Q wave myocardial infarction, the incidence of death and nonfatal infarction or reinfarction was low but not trivial after 1 year (4.3% mortality, 8.8% nonfatal infarction). An early invasive management strategy was associated with slightly more coronary angioplasty procedures but equivalent numbers of bypass surgery procedures than a more conservative early strategy of catheterization and revascularization only for signs of recurrent ischemia. The incidence of death or nonfatal infarction, or both, did not differ after 1 year by strategy assignment, but fewer patients in the early invasive strategy group underwent later repeat hospital admission (26% vs. 33%, p < 0.001). Either strategy is appropriate for patient management; differences in hospital admissions and revascularization procedures, with their attendant costs, are likely to be minimal.
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Affiliation(s)
- H V Anderson
- University of Texas Health Science Center, Houston 77225, USA
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Bankwala Z, Swenson LJ. Unstable angina pectoris. Postgrad Med 1995; 98:155-165. [PMID: 29224441 DOI: 10.1080/00325481.1995.11946092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Preview Patients with angina that occurs increasingly often, for longer periods, with less and less exertion, or during periods of rest are of particular concern. These traits are all characteristic of unstable angina. Unlike stable angina, which has a relatively benign course, unstable angina has the capability of progressing to acute myocardial infarction or death. The authors summarize patient evaluation, with emphasis on identification of those at risk.
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Affiliation(s)
- H V Anderson
- University of Texas Health Science Center, Houston, USA
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Garcia-Dorado D, Théroux P, Tornos P, Sambola A, Oliveras J, Santos M, Soler Soler J. Previous aspirin use may attenuate the severity of the manifestation of acute ischemic syndromes. Circulation 1995; 92:1743-8. [PMID: 7671356 DOI: 10.1161/01.cir.92.7.1743] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The present study was designed to investigate whether the prior use of aspirin could influence the severity of the manifestation of acute coronary artery syndromes, given the well-documented observations that aspirin can prevent myocardial infarction, stroke, and death in cardiovascular disease. METHODS AND RESULTS A series of 539 consecutive patients admitted to the Coronary Care Unit of a General Hospital was carefully characterized in a study with an ambidirectional design, with regard to previous medical history, aspirin use, and subsequent hospital diagnosis. Among the 214 patients previously taking aspirin, the hospital diagnosis was myocardial infarction in 24% and unstable angina in 76% compared with 54% and 46%, respectively, among the 325 not taking aspirin (P < .0001), for a reduction in the odds ratio of myocardial infarction with aspirin of 72% (95% CI, 59% to 90%). The decrease in odds was homogeneous in all subsets studied and independent of age, sex, previous angina, or previous myocardial infarction. The myocardial infarction was of a Q-wave type in 62% of aspirin users compared with 76% of nonusers (P < .05). By multivariate analysis, previous aspirin use was a strong predictor of unstable angina versus myocardial infarction and the only independent predictor of non-Q-wave versus Q-wave myocardial infarction. CONCLUSIONS This study, thus, suggests a shift to less severe manifestation of acute coronary syndromes with aspirin use, implying that the failure of the drug in many patients with an acute coronary syndrome is only partial and that aspirin has the potential of attenuating the severity of the underlying acute thrombotic disease process.
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Affiliation(s)
- D Garcia-Dorado
- Service of Cardiology, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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Abstract
The term unstable angina encompasses heterogeneous clinical syndromes. Fissuring of an atherosclerotic coronary artery plaque with superimposed platelet deposition, with or without additional thrombus formation, is invariably responsible for a prolonged episode of angina at rest, increasing frequency of angina at rest, or with minimal exertion of less than 4 weeks in duration and early postinfarction angina. Plaque progression, rather than plaque fissuring, is the most likely mechanism for progressive reduction in walking distance due to angina in patients who previously have stable angina. Coronary artery spasm is responsible for Prinzmetal's variant angina, but its exact role in other forms of unstable angina is unknown. The mainstay of treatment of unstable angina (prolonged episode of angina at rest and recent onset angina at rest, or with minimal exertion with a crescendo pattern) is aspirin, heparin, or both. Both aspirin and intravenous (i.v.) heparin or their combination reduce early mortality and the incidence of acute myocardial infarction in patients hospitalized with unstable angina. However, these agents do not promptly relieve chest pain. There are no placebo-controlled studies evaluating the usefulness of nitrates in unstable angina. In open-label studies, continuous therapy with i.v. nitroglycerin (NTG) for 24 hours or longer has been shown to relieve chest pain in patients with rest angina refractory to therapy with other antianginal agents, including long-acting nitrates. Recurrence of chest pain in patients receiving i.v. NTG is a common problem and probably represents development of pharmacologic tolerance, but this can be overridden by dose escalation; protracted tolerance during short-term use of i.v. NTG is usually not a problem.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- U Thadani
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City 73104
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Théroux P, Waters D, Qiu S, McCans J, de Guise P, Juneau M. Aspirin versus heparin to prevent myocardial infarction during the acute phase of unstable angina. Circulation 1993; 88:2045-8. [PMID: 8222097 DOI: 10.1161/01.cir.88.5.2045] [Citation(s) in RCA: 193] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Antiplatelet therapy with aspirin and antithrombotic therapy with heparin both prevent the complications of unstable angina; however, no definitive data exist on the relative clinical efficacy of the two drugs. METHODS AND RESULTS Aspirin (325 mg bid) or heparin (5000-U intravenous bolus followed by a perfusion titrated to the APTT) were compared in a double-blind randomized trial of 484 patients in two cohorts enrolled sequentially. The study was initiated at admission to hospital at a mean of 8.3 +/- 7.8 hours after the last episode of pain. End points were assessed 5.7 +/- 3.3 days later, when the decision for long-term management was made. Myocardial infarction occurred in 2 (0.8%) of the 240 patients randomized to heparin and in 9 (3.7%) of the 244 randomized to aspirin (P = .035), an odds ratio of 0.22 and a risk difference of 2.9% (95% confidence limits, 0.3% to 5.6%) with heparin. The only death resulted from a myocardial infarction in an aspirin patient. Survival curves with Cox logistic regression analysis showed that the improvement in survival without myocardial infarction with heparin (P = .035) was independent of other baseline characteristics. CONCLUSIONS This study documents that heparin prevents myocardial infarction better than aspirin during the acute phase of unstable angina.
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Affiliation(s)
- P Théroux
- Department of Medicine, Montreal Heart Institute, Canada
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