A Focus On: Modern therapy of unstable angina — invasive vs. conservative management

A Focus On: Modern therapy of unstable angina — invasive vs. conservative management


Video 24.8. Acute pulmonary embolism. TTE. Note dilated right heart with McConnell’s sign and paradoxical septal movements in a patient referred to the ER from the regional hospital due to suspected unstable angina. Echo-free space in front of the heart represents pericardial fat pad. Reproduced from Chapter 24: Echocardiography in the emergency room, in The EAE Textbook of Echocardiography. Edited by Leda Galiuto, Luigi Badano, Kevin Fox, Rosa Sicari, and Jose Luis Zamorano. © European Society of Cardiology. DOI: 10.1093/med/9780199599639.001.0001


The optimal therapy of patients presenting with unstable angina with or without enzyme rise but without ST elevation (UA/NSTEMI) is still debatable. Several (FRISC II, TACTICS-TIMI 18, RITA 3, ISAR-COOL, TIMACS), although not all (ICTUS, ELISA, OPTIMA, ABOARD, LIPSIA-NSTEMI), randomized trials have provided evidence in favour of an invasive strategy compared to conservative medical therapy in non-ST elevation acute coronary syndromes (NSTE-ACS). Overall, the invasive strategy appears to provide better long-term outcomes.1, 2


In addition, five-year follow-up of patients with non–ST-elevation acute coronary syndrome from FRISC II, ICTUS, and RITA-3 trials showed no association between a procedure-related MI and long-term cardiovascular mortality, although there was a substantial increase in long-term mortality after a spontaneous MI.3 This is particularly true in high risk patients, i.e. those with features such as refractory angina, haemodynamic or electrical instability, marked enzyme rise, or dynamic ST-T changes. It is also beneficial in diabetic patients. In low-risk patients and especially women, a conservative management with a view to intervention if indicated can be adopted. Thus, current guidelines suggest that in high-risk patients, intervention within 12–72 hours is preferred while either an early or a delayed approach may be adopted in other patients.4, 5, 6


The optimal timing of coronary angiography and subsequent intervention if indicated, (i.e. immediately after admission or after pre-treatment with optimal medical therapy including potent antiplatelet agents) is also debated.7, 8 Delayed catheterization has been thought to allow plaque passivation by pre-treatment with optimal antithrombotic medication, and avoidance adverse outcomes, perhaps due to embolic phenomena, by early intervention.  However, very early angiography (<14 h) with a view to PCI if indicated may be superior to a strategy of preceding anticoagulation and subsequent intervention in patients with NSTE-ACS, by reducing residual ischemia and the duration of hospital stay and may also reduce complications, such as bleeding, and major events (death, MI, or stroke).8


Further reading

1. Bavry, A.A., Kumbhani, D.J., Rassi, A.N., et al. Benefit of early invasive therapy in acute coronary syndromes: A meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol. 2006;48:1319-1325

2. Fox, K.A., Clayton, T.C., Damman, P., et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-st-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010;55: 2435-2445

3. Damman, P., Wallentin, L., Fox, K.A., et al. Long-term cardiovascular mortality after procedure-related or spontaneous myocardial infarction in patients with non-st-segment elevation acute coronary syndrome: A collaborative analysis of individual patient data from the FRISC II, ICTUS, and RITA-3 trials (fir). Circulation. 2012;125:568-576

4. 2012 ACCF/AHA Focused Update Incorporated into the ACCF/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction. . JACC 2013:doi.org/10.1016/j.jacc.2013.1001.1014

5. Hamm, C.W., Bassand, J.P., Agewall, S., et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The task force for the management of acute coronary syndromes (acs) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (esc). Eur Heart J. 2011;32:2999-3054

6. Levine, G.N., Bates, E.R., Blankenship, J.C., et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574-651

7. Navarese, E.P., Gurbel, P.A., Andreotti, F., et al. Optimal Timing of Coronary Invasive Strategy in Non-ST-Segment Elevation Acute Coronary Syndromes: A systematic review and meta-analysis. Ann Intern Med.b. 2013 158:261-270.

8. Katritsis, D.G., Siontis, G.C., Kastrati, A., et al. Optimal timing of coronary angiography and potential intervention in non-st-elevation acute coronary syndromes. Eur Heart J. 2011;32:32-40.


Demosthenes G. Katritsis, Director, Department of Cardiology, Athens Euroclinic, Greece, and Honorary Consultant Cardiologist, St Thomas' Hospital, London, UK.

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