Unstable angina: Comparison of medical and surgical management

doi:10.1016/S0002-9149(77)80137-9

The American Journal of Cardiology

Volume 39, Issue 5, 1977, Pages 734-740

https://doi.org/10.1016/S0002-9149(77)80137-9 Get rights and content

Medical versus surgical treatment of unstable angina was compared in a prospective nonrandomized study of 118 patients. Acute transient ST-T wave changes were present during chest pain in all patients. Acute infarction was excluded by serial electrocardiograms and enzyme studies. All patients admitted to the coronary care unit from 1970 to 1975 who fulfilled the entry criteria were included in the study. The starting point for data evaluation was 5 days after hospital admission. Characteristics at entry were similar in 66 medically treated patients and 52 patients who had coronary bypass vein graft surgery. During a mean follow-up period of 23 months in 66 medically treated patients with unstable angina the incidence rate of nonfatal myocardial infarction was 17 percent and the total mortality rate 21 percent compared with respective rates of 19 percent and 5.8 percent in 52 surgically treated patients. In the surgical group 8 patients (15 percent) had a perioperative infarction and only 2 (4 percent) had a late infarction; one patient (2 percent) died at operation. Symptomatic improvement was observed more frequently in the surgically treated group. Sixty percent of surgically treated patients were free of angina compared with 21 percent of medically treated patients. Eight medically treated patients (12 percent) required late surgical treatment for persistent severe angina despite optimal medical management.

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Cited by (42)

Acute coronary syndromes: Interventions
1999, Lancet
Outcome of percutaneous transluminal coronary angioplasty in subsets of unstable angina pectoris. A report of the 1985-1986 National Heart, Lung, and Blood Institute and percutaneous transluminal coronary angioplasty registry
1994, Journal of the American College of Cardiology
Objectives. The purpose of this study was to characterize the outcome of coronary angioplasty according to the various presentations of unstable angina pectoris.
Background. Although unstable angina is a mosaic of clinical manifestations, a comprehensive analysis of short- and long-term outcome of coronary angioplasty in subsets of unstable angina is not available.
Methods. Data from 15 clinical centers for the 857 patients with unstable angina in the 1985–1986 National Heart, Lung, and Blood Institute percutaneous transluminal coronary angioplasty registry were analyzed. Five-year follow-up was available in > 96.5%. Patients were first classified as those with (679 [79%]) or without (178 [21%]) rest angina. Patients were also allocated to five mutually exclusive categories of decreasing unstable angina severity: postinfarction angina, acute coronary insufficiency, plain rest angina, accelerating angina and new onset angina.
Results. The group with rest angina had more older patients (p < 0.01) and women (p < 0.001), and a greater proportion had a previous myocardial infarction (p < 0.001) and a left ventricular ejection fraction ≤ 50% (p < 0.01) than did the group without rest angina. Angiographic characteristics were nearly the same, whereas procedural characteristics and outcome were the same for both categories. At 5-year follow-up, there was a higher crude mortality rate in patients with than without rest angina (p < 0.05). Resolution into five subsets yielded additional information. Women were more represented only in the acute coronary insufficiency and plain rest angina subsets (p < 0.001). Patients with angina after myocardial infarction had the second shortest history of angina (p < 0.001), the highest percent of smokers (p < 0.01) and, with those with acute coronary insufficiency, the highest incidence of congestive heart failure (p < 0.05) and an ejection fraction ≤ 50% (p < 0.001). They had the highest percent of totally occluded arteries, coronary thrombus and collateral blood flow received but also the lowest rate of severe stenoses (p < 0.001 for all). Patients with new onset angina had the highest prevalence of single-vessel disease (p < 0.05), critical and complex stenoses (p < 0.001) and no coronary angioplasty-related deaths. The crude 5-year mortality rate was higher for both postinfarction and acute insufficiency groups (p < 0.05) than for the other subsets. After adjustments for risk factors, no significant differences in adverse event rates remained among the different unstable angina subgroups.
Conclusions. Analysis of the diverse clinical presentations of unstable angina supports underlying pathogenetic differences. Coronary angioplasty is safe and effective in all subsets of unstable angina. Long-term survival is good in general but is related to the baseline status of left ventricular function.
Clinical and coronary arteriographic features and outcome of recent onset unstable angina
1993, International Journal of Cardiology
Fifty consecutive patients (43 male and seven female; mean age 51.8 years) with recent onset angina (24.6% of all admissions for unstable angina during a 1-year period) underwent coronary arteriography. Most patients (96.8%) presented with severe angina (Canadian Cardiovascular Society Class III–IV) with admission ECG changes of myocardial ischemia in 46%. Echocardiography (within 2 days of admission) showed normal left ventricular function (LVEF > 50%) in 80% and mild or moderate impairment (LVEF 35–49%) in 12% of patients. Segmental wall motion abnormalities were noted in a small number (12.9%). Coronary angiography revealed significant (≥ 70% diameter stenosis) disease in one vessel in 14 (28%), in two vessels in seven (14%), three vessels in 22 (44%) and no disease in seven (14%) patients. Significant left main stenosis (≥ 50% diameter stenosis) was present in two (5%) patients. Left anterior descending artery was more commonly involved (66%) as compared to the other arteries. A significantly higher incidence of multivessel disease was observed in patients with diabetes mellitus (P < 0.003) and in smokers (P < 0.04). Multiple coronary artery involvement was more common in patients with three or more risk factors for coronary artery disease (P < 0.005). In-hospital non fatal myocardial infarction occurred in three (6%) patients. During follow-up (average 13 ± 1.28 months) 30 (60%) patients underwent coronary artery bypass surgery, 13 (26%) required coronary angioplasty while seven (14%) were managed by drugs alone with no further mortality and significant symptomatic relief. Patients with recent onset angina, in our setting, frequently have severe multiple vessel coronary artery disease. Early evaluation of such patients is important for appropriate management to reduce morbidity and mortality.
Morphology of left anterior descending coronary territory lesions as a predictor of anterior myocardial infarction: A CASS registry study
1989, Journal of the American College of Cardiology
Despite a growing awareness of the correlation of coronary artery stenoses morphology with clinical syndromes, no comprehensive, prospective analysis of the implications of stenosis morphology on risk of myocardial infarction has been reported. Angiograms from 118 patients, representative of the 4.9% of medically treated Coronary Artery Surgery Study (CASS) patients who during subsequent 3 year follow-up study had an anterior myocardial infarction, were matched on the basis of arteriographic anatomy and disease with 141 patients who did not have an anterior infarction. Angiograms from these 259 patients with 557 left anterior descending artery stenoses were reviewed without knowledge of clinical outcome. Conditional regression analyses were performed to determine the importance of stenosis morphology, relative to computer-determined stenosis severity and other clinical variables, in the prediction of risk of infarction.
Univariate analysis revealed luminal roughness (odds ratio 4.5; p = 0.001) and lesion length (odds ratio 1.7 per unit length; p = 0.007) to be highly correlated with future risk of infarction. Multivariate analysis revealed left anterior descending artery percent stenosis >_50%, lesion roughness, left circumflex artery stenosis and smoking, in that order, to be predictive of anterior myocardial infarction, whereas 22 other morphologic variables were not independently predictive of outcome. The importance of stenosis roughness may relate to its propensity for thrombogenesis and should be considered in clinical decision making.
Percutaneous transluminal coronary angioplasty in patients with stable and unstable angina pectoris: Analysis of early and late results
1983, American Heart Journal
Percutaneous transluminal coronary angioplasty (PTCA) was performed in 50 patients with stable and in 50 patients with unstable angina pectoris, each patient showing an isolated stenosis of more than 80% of the cross-sectional area of a single coronary artery. The technical success rate was 66% in the stable groups (26 of 37 patients [70%] with left anterior descending artery [LAD], 7 of 12 patients [58%] with right coronary artery [RCA]) and 74% in the unstable group (27 of 34 patients [79%] with LAD, 10 of 15 patients [67%] with (RCA). The increase in stenotic area in the unstable group exceeding that in the stable group for LAD stenoses (41.5 ± 15.1% vs 32.3 ± 14.5%, p < 0.03), while in RCA stenoses the results in the stable group were better (45.1 ± 17.6% vs 32.7 ± 12.3%, n.s.). One acute vessel occlusion necessitating an emergency bypass operation occurred in each group (2%). The patient in the stable group died (total mortality rate 1%). Sixty-three of the successfully treated patients were routinely restudied 6 months later. According to clinical symptoms, 23% of the stable and 36% of the unstable group were in functional classes III and IV. From the anatomical viewpoint, a restenosis (>85%) was found in 17% of the stable and in 24% of the unstable group. A further spontaneous decrease (>10%) of the vessel obstruction was found in 47% of the stable group and in 12% of the unstable group. The results show that PTCA can be carried out with equally low risks and comparable good early and late results, both in patients with stable and with unstable angina.
The effect of coronary bypass surgery on survival
1983, Progress in Cardiovascular Diseases

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^*: This manuscript was supported by research funds from the Palo Alto Veterans Administration Hospital, Palo Alto, California.

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Report On TherapyUnstable angina: Comparison of medical and surgical management*

Am J Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Report On Therapy
Unstable angina: Comparison of medical and surgical management*