Download PDF
Hamostaseologie 2000; 20(01): 53-58
DOI: 10.1055/s-0037-1619469
Original article
Schattauer GmbH

Instabile Angina pectoris

Interventionelle versus pharmakologische TherapieUnstable Angina pectorisInterventional versus Pharmacological Treatment
Ch. Kaiser
1   Abteilung für Kardiologie, Kantonsspital Basel, Schweiz
,
M. E. Pfisterer
1   Abteilung für Kardiologie, Kantonsspital Basel, Schweiz
› Author Affiliations
Further Information

Publication History

Publication Date:
22 December 2017 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

In den letzten Jahren wurden bei der instabilen Angina pectoris sowohl im Bereich des pathophysiologischen Verständnisses, der Risikostratifizierung als auch der Therapie große Fortschritte unternommen. Nebst besserer klinischer Risikostratifizierung stehen uns heute ebenfalls biochemische Marker wie z.B. das Troponin zur initialen Risikoabschätzung zur Verfügung. Zusätzlich zur Standardtherapie mit Azetylsalizylsäure und der intravenösen Vollheparinisierung verfügen wir über neuere Medikamente wie die niedermolekularen Heparine sowie die GPIIb/IIIa-Rezeptorantagonisten, welche in größeren Studien mit oder ohne koronare Intervention ihre Wirksamkeit bewiesen haben, vorerst jedoch vor allem den Hochrisikopatienten vorbehalten sein sollten. Die interventionelle Therapie wurde insbesondere durch die Entwicklung von koronaren Stents verbessert, die Wahl des richtigen Zeitpunkts der Intervention bleibt jedoch kontrovers.

Summary

Over recent years many advances have been realized in the pathophysiological understanding, risk stratification and treatment of unstable angina pectoris. Besides better clinical risk stratification biochemical markers such as Troponin are used today, which allow a better individual risk evaluation. New therapeutic agents like low molecular heparins and Platelet glycoprotein IIb/IIIa antagonists have been added to standard therapy with aspirin and intravenous heparin and have prooven their efficacy in major clinical trials with or without coronary intervention. Only high risk patients however should be treated with these agents at the moment. Interventional therapy has been improved especially with the introduction of coronary stents. The timing of coronary intervention in unstable angina, however, remains controversial.

Schlüsselwörter

Troponin - GPIIb/IIIa-Rezeptorantagonisten - niedermolekulares Heparin - PTCA/Stentimplantation

Keywords

Troponin - platelet glycoprotein IIb/IIIa antagonists - low molecular weight heparin - PTCA/stent-implantation
 

  • Literatur

  • 1 Ambrose JA. Plaque disruption and the acute coronary syndromes of unstable angina and myocardial infarction: if the substrate is similar, why is the clinical presentation different?. J Am Coll Cardiol 1992; 19: 1653-8.
    CrossrefPubMedGoogle Scholar
  • 2 Antmann EM. Dose-ranging trial of enoxaparin for unstable angina: results of TIMI11A trial. J Am Coll Cardiol 1997; 29: 1474-82.
    CrossrefPubMedGoogle Scholar
  • 3 Benamer H, Steg PG, Benessiano J. et al. Elevated cardiac troponin I predicts a high-risk angiographic anatomy of the culprit lesion in unstable angina. Am Heart J 1999; 137: 815-20.
    CrossrefPubMedGoogle Scholar
  • 4 Berger PB, Bell MR, Hasdai D. et al. Safety and efficacy of ticlopidine for only two weeks after successfull intracoronary stent placement. Circulation 1999; 99: 248-53.
    CrossrefPubMedGoogle Scholar
  • 5 Boden WE, O’Rourke RA, Crawford MH. et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med 1998; 338: 1785-92.
    CrossrefPubMedGoogle Scholar
  • 6 Braunwald E. Unstable Angina: A Classification. Circulation 1989; 80: 410-4.
    CrossrefPubMedGoogle Scholar
  • 7 Braunwald E, Jones RH, Mark DB. Diagnosing and Managing Unstable Angina. Circulation 1994; 90: 613-22.
    CrossrefPubMedGoogle Scholar
  • 8 Braunwald E. Unstable Angina: An Etiologic Approach to Management. Circulation 1998; 98: 2219-22.
    CrossrefPubMedGoogle Scholar
  • 9 Bugiardini R, Pozzati A, Borghi A. et al. Angiographic morphology in unstable angina and its relation to transient myocardial ischemia and hospital outcome. Am J Cardiol 1991; 67: 460-4.
    CrossrefPubMedGoogle Scholar
  • 10 Bugiardini R, Borghi A, Pozzati A. et al. Relation of severity of symptoms to transient myocardial ischemia and prognosis in unstable angina. J Am Coll Cardiol 1995; 25: 597-604.
    CrossrefPubMedGoogle Scholar
  • 11 Burkhard-Meier C, Deutsch HJ, Erdmann E. Aktuelle Therapie der instabilen Angina pectoris. Dtsch med Wschr 1999; 124: 733-9.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Cannon CP. Advances in the medical management of acute coronary syndromes. Curr Opin Cardiol 1998; 13: 327-47.
    CrossrefPubMedGoogle Scholar
  • 13 Cohen M, Demers C, Gurfinkel EP. the ESSENCE Investigators. A comparison of lowmolecular-weight heparin with unfractionated heparin for unstable coronary artery disease. N Engl J Med 1997; 337: 447-52.
    CrossrefPubMedGoogle Scholar
  • 14 Collier BS, Folts JD, Scudder LE. Antithrombotic effect of a monoclonal antibody to the platelet glycoprotein IIb/IIIa receptor in an experimental animal model. Blood 1986; 68: 783-6.
    PubMedGoogle Scholar
  • 15 Dangas C, Mehran R, Wallenstein S. et al. Correlation of Angiographic Morphology and Clinical Presentation in Unstable Angina. J Am Coll Cardiol 1997; 29: 519-25.
    CrossrefPubMedGoogle Scholar
  • 16 Deligonul U, Gabliani G, Caralis D. et al. Percutaneous transluminal coronary angioplasty in patients with intracoronary thrombus. Am J Cardiol 1988; 62: 474-6.
    CrossrefPubMedGoogle Scholar
  • 17 de Feyter PJ, Serruys PW, Soward A. et al. Coronary angioplasty for early postinfarction unstable angina. Circulation 1986; 74: 1365-70.
    CrossrefPubMedGoogle Scholar
  • 18 Depré C, Wijns W, Robert AM. et al. Pathology of Unstable Plaque: Correlation With the Clinical Severity of Acute Coronary Syndromes. J Am Coll Cardiol 1997; 30: 694-702.
    CrossrefPubMedGoogle Scholar
  • 19 De Wood MA, Stiffer WF, Simpson CS. et al. Coronary angiographic findings soon after non-Q wave myocardial infarction. N Engl J Med 1986; 315: 417-23.
    CrossrefPubMedGoogle Scholar
  • 20 Falk E, Shah P, Fuster V. Coronary plaque disruption. Circulation 1995; 92: 656-71.
    PubMedGoogle Scholar
  • 21 FRISC study group. Low molecular weight heparin (Fragmin) during instability in coronary artery disease (FRISC). Lancet 1996; 347: 561-8.
    CrossrefPubMedGoogle Scholar
  • 22 Fulton W. Pathological concepts in acute coronary thrombosis: relevance to treatment. Br Heart J 1993; 70: 403-8.
    CrossrefPubMedGoogle Scholar
  • 23 Fuster V, Badimon L, Cohen M. et al. Insights into the pathogenesis of acute ischemic syndromes. Circulation 1988; 77: 1213-20.
    CrossrefPubMedGoogle Scholar
  • 24 Fuster V, Lewis A. Conner Memorial Lecture: Mechanisms leading to myocardial infarction: insights from the studies of vascular biology. Circulation 1994; 90: 2126-46.
    CrossrefPubMedGoogle Scholar
  • 25 Harrington RA. for the PURSUIT investigators. A symposium: acute ischemic coronary syndromes-The PURSUIT Trial. Am J Cardiol 1997; 80: 36B-8B.
    PubMedGoogle Scholar
  • 26 Harrington RA, Moliterno DJ, Van de Werf F. et al. for the PARAGON Investigators. Delaying and preventing ischemic events in patients with acute coronary syndromes using the platelet glycoprotein IIb/IIIa inhibitor lamifiban. (abstract). J Am Coll Cardiol 1997; 29: 409A.
    CrossrefPubMedGoogle Scholar
  • 27 Lincoff A, Popma J, Ellis S. et al. Abrupt vessel closure complicating coronary angioplasty: clinical, angiographic and therapeutic profile. Am Coll Cardiol 1992; 19: 926-35.
    CrossrefPubMedGoogle Scholar
  • 28 Lotan CS, Jonas M, Rozenman Y. et al. Comparison of early invasive and conservative treatments in patients with anterior wall non-Q-wave acute myocardial infarction. Am J Cardiol 1995; 76: 330-6.
    CrossrefPubMedGoogle Scholar
  • 29 Mizuno K, Satamura K, Miyamoto A. et al. Angioscopic evaluation of coronary artery thrombi in acute coronary syndromes. N Engl J Med 1992; 326: 287-91.
    CrossrefPubMedGoogle Scholar
  • 30 Moreno PR, Falk E, Palacios IF. et al. Macrophage infiltration in acute coronary syndromes: implications for plaque rupture. Circulation 1994; 90: 775-8.
    CrossrefPubMedGoogle Scholar
  • 31 Musa Khan M, Ellis S, Aguirre F. et al. Does intracoronary thrombus influence the outcome of high risk percutaneous transluminal coronary angioplasty? Clinical and angiographic outcomes in a large multicenter trial. J Am Coll Cardiol 1998; 31: 31-6.
    PubMedGoogle Scholar
  • 32 Sätre H, Holmwang L, Wagner GS. et al. Reduction of myocardial damage by prolonged treatment with subcutaneous low molecular weight heparin in unstable coronary artery disease. Eur Heart J 1999; 20: 645-52.
    CrossrefPubMedGoogle Scholar
  • 33 The CAPTURE Investigators. Randomized placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina. Lancet 1997; 349: 1429-35.
    CrossrefPubMedGoogle Scholar
  • 34 The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994; 330: 956-61.
    CrossrefPubMedGoogle Scholar
  • 35 The EPILOG Investigators. Platelet glycoprotein IIa/IIIb receptor blockade and low-dose heparin during percutaneous coronary revascularisation. N Engl J Med 1997; 336: 1689-96.
    CrossrefPubMedGoogle Scholar
  • 36 The global use of stategies to open occluded coronary arteries (GUSTO IIa) Investigators. Randomised trial of intravenous heparin versus recombinant hirudin for acute coronary syndromes. Circulation 1994; 90: 1631-7.
    CrossrefPubMedGoogle Scholar
  • 37 The IMPACT-II Investigators. Randomised placebo-controlled trial of effect of eptifibatide on complications of percutaneous coronary interventions: IMPACT-II. Lancet 1997; 349: 1422-8.
    CrossrefPubMedGoogle Scholar
  • 38 The PRISM Study Investigators. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. N Engl J Med 1998; 338: 1498-505.
    CrossrefPubMedGoogle Scholar
  • 39 The PRISM-PLUS Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina an non-Q-wave myocardial infarction. N Engl J Med 1998; 338: 1488-97.
    CrossrefPubMedGoogle Scholar
  • 40 The RESTORE Investigators. Effect of Platelet Glycoprotein IIb/IIIa blockade with Tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. Circulation 1997; 96: 1445-53.
    CrossrefPubMedGoogle Scholar
  • 41 The RISC Group. Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. Lancet 1990; 336: 827-30.
    CrossrefPubMedGoogle Scholar
  • 42 Théroux P, Ouimet H, McCans J. et al. Aspirin, heparin or both to treat acute unstable angina. N Engl J Med 1988; 319: 1105-11.
    CrossrefPubMedGoogle Scholar
  • 43 Théroux P, Kanz S, Roy L. the Canadian Lamifiban Study Investigators. Platelet membrane receptor glycoproteins IIb/IIIa antagonism in unstable angina. Circulation 1996; 94: 899-905.
    CrossrefPubMedGoogle Scholar
  • 44 Théroux P, Fuster V. Acute Coronary Syndromes: Unstable Angina and Non-Q-Wave Myocardial Infarction. Circulation 1998; 97: 1195-206.
    CrossrefPubMedGoogle Scholar
  • 45 The TIMI IIIB Investigators. Effects of Tissue Plasminogen Activator and a Comparison of Early Invasive and Conservative Stragegies in Unstable Angina and Non-Q-Wave Myocardial Infarction, Results of the TIMI IIIB Trial. Circulation 1994; 89: 1545-56.
    CrossrefPubMedGoogle Scholar
  • 46 Vaitkus P, Herrmann H, Laskey W. Management and immediate outcome of patients with intracoronary thrombus during percutaneous transluminal coronary angioplasty. Am Heart J 1992; 124: 1-8.
    CrossrefPubMedGoogle Scholar
  • 47 Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. JAMA 1988; 260: 2259-63.
    CrossrefPubMedGoogle Scholar
  • 48 Zaacks SM, Liebson PR, Calvin JE. et al. Unstable Angina and Non-Q Wave Myocardial Infarction: Does the Clinical Diagnosis Have Therapeutic Implications?. J Am Coll Cardiol 1999; 33: 107-18.
    CrossrefPubMedGoogle Scholar