Report on therapy
Unstable angina: Natural history and determinants of prognosis

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Abstract

One hundred one patients with unstable angina were treated conservatively without the routine use of beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents or nitrates. Only two patients underwent arteriography and coronary arterial bypass surgery during hospitalization and one patient during the 1st year of follow-up study. The 28 day mortality rate was 4 percent and the total 1 year cardiac mortality rate 10 percent. Two patients died from carcinoma. The incidence rate of nonfatal myocardial infarction was 9 percent during the first 28 days and a further 3 percent for the 1st year. These results compare favorably with the immediate and 1 year prognosis reported from other studies using different treatment procedures, including modern intensive drug treatment and coronary arterial bypass surgery. Various factors studied during the acute stage of unstable angina were assessed in an effort to predict the immediate and long-term outcome. Only persistence of pain after admission to the hospital was found a significant indicator of an adverse prognosis.

Modern medical treatment of unstable angina with beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents, nitrates and antiarrhythmic agents is critically examined. The paucity of proper randomized controlled studies confirming the value of medication is underlined. There is little evidence to show that aggressive or intensive medical or surgical treatment is superior to a conservative approach to management in the coronary care unit. This approach includes bed rest until the pain has resolved, symptomatic drug treatment only, the minimal use of invasive investigations and careful risk factor intervention.

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    In this study, DSE performed early after an acute episode of UA in medically treated patients was a better and more specific predictor of cardiac events during follow-up than exercise electrocardiography, especially when considering the incidence of MI and cardiac death. The prognosis of patients who have an acute episode of UA is very variable, with incidences of MI and death at 1 year after hospital admission ranging from 13% to 25%.12,13 Although the optimal management approach for these patients is still open to debate,14,15 risk stratification is usually recommended to identify those patients at a higher risk of further cardiac events who must undergo a more aggressive treatment.2,3

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This study was supported by The Medical Research Council of Ireland, Dublin, Ireland.

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