Relation between clinical presentation and angiographic findings in unstable angina pectoris, and comparison with that in stable angina

doi:10.1016/0002-9149(93)90349-H

The American Journal of Cardiology

Volume 72, Issue 7, 1 September 1993, Pages 544-550

https://doi.org/10.1016/0002-9149(93)90349-H Get rights and content

Abstract

The diagnosis of unstable angina encompasses a broad spectrum of patients with myocardial ischemia, varying widely in cause, prognosis and responsiveness to therapy. A new clinical classification of unstable angina is based on the following 2 components: severity, and the clinical setting in which unstable angina develops. The hypothesis that this clinical classification correlates with the underlying coronary artery anatomy was tested. In 238 consecutive patients, an unstable angina score ranging from 2 to 6 was determined by adding the scores for severity (1 = unstable angina without pain at rest; 2 = pain at rest >48 hours before angiography; and 3 = pain at rest ≤48 hours before angiographic evaluation) and the clinical setting of unstable angina (1 = unstable angina secondary to a noncardiac condition; 2 = primary unstable angina; and 3 = early postinfarction unstable angina). Fifty concurrently studied consecutive patients with stable angina were assigned a score of 0. Patients with unstable angina averaged 63 ± 11 years of age, and 165 were men (69%). Pain at rest occurred in 202 of 238 patients (85%), and angiography was performed ≤48 hours in 139 of these patients (69%). Among patients with unstable angina, 5 (2%) had secondary unstable angina, 143 (60%) had primary unstable angina, and 90 (38%) had postinfarction unstable angina. Multivariable regression analysis identified the unstable angina score as the most important predictor of intracoronary thrombus (p = 0.011) and lesion complexity (p = 0.004) in the ischemia-related artery. The new clinical classification of unstable angina correlates with the underlying angiographic anatomy, and may thus aid in decisions regarding diagnostic procedures and provide a useful basis for comparing the response to therapy among patients with unstable angina.

References (28)

AE Williams et al.
Angiographic morphology in unstable angina pectoris
Am J Cardiol
(1988)
R Bugiardini et al.
Angiographic morphology in unstable angina and its relation to transient myocardial ischemia and hospital outcome
Am J Cardiol
(1991)
R Rehr et al.
Angiographic morphology of coronary artery stenoses in prolonged rest angina: evidence of intracoronary thrombus
J Am Coll Cardiol
(1989)
C de Zwaan et al.
Effects of thrombolytic therapy on unstable angina: clinical and angiographic results
J Am Coll Cardiol
(1988)
EJ Topol et al.
Coronary revascularization after intravenous tissue plasminogen activator for unstable angina pectoris: results of a randomized, double-blind, placebo-controlled trial
Am J Cardiol
(1988)
JA Ambrose et al.
Angiographic morphology and the pathogenesis of unstable angina pectoris
J Am Coll Cardiol
(1985)
G Capone et al.
Frequency of intracoronary filling defects by angiography in angina pectoris at rest
Am J Cardiol
(1985)
X Bosch et al.
Early postinfarction ischemia: clinical, angiographic, and prognostic significance
Circulation
(1987)
MR Freeman et al.
Intracoronary thrombus and complex morphology in unstable angina. Relation of timing of angiography and in-hospital cardiac events
Circulation
(1989)
K Gotoh et al.
The role of intracoronary thrombus in unstable angina: angiographic assessment and thrombolytic therapy during ongoing anginal attacks
Circulation
(1988)

CT Sherman et al.

Coronary angioscopy in patients with unstable angina pectoris

N Engl J Med

(1986)

K Mizuno et al.

Angioscopic evaluation of coronary-artery thrombi in acute coronary syndromes

N Engl J Med

(1992)

HK Gold et al.

A randomized, blinded, placebo-controlled trial of recombinant tissue-type plasminogen activator in patients with unstable angina pectoris

Circulation

(1987)

P Theroux et al.

Aspirin, heparin, or both to treat acute unstable angina

N Engl J Med

(1988)

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Citation Excerpt :
The Braunwald classification has been widely used because of its effectiveness in evaluating severity and prognosis of UAP. Severity and clinical setting of UAP have been related to lesion complexity.16–18 Moreover, Braunwald19 proposed different causal processes: (1) a nonocclusive thrombus on preexisting plaque, (2) dynamic obstruction (coronary spasm), (3) progressive mechanical obstruction, and (4) inflammation and/or infection.
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Relation between clinical presentation and angiographic findings in unstable angina pectoris, and comparison with that in stable angina

Abstract

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Early postinfarction ischemia: clinical, angiographic, and prognostic significance

Circulation

Intracoronary thrombus and complex morphology in unstable angina. Relation of timing of angiography and in-hospital cardiac events

Circulation

The role of intracoronary thrombus in unstable angina: angiographic assessment and thrombolytic therapy during ongoing anginal attacks

Circulation

Coronary angioscopy in patients with unstable angina pectoris

N Engl J Med

Angioscopic evaluation of coronary-artery thrombi in acute coronary syndromes

N Engl J Med

A randomized, blinded, placebo-controlled trial of recombinant tissue-type plasminogen activator in patients with unstable angina pectoris

Circulation

Aspirin, heparin, or both to treat acute unstable angina

N Engl J Med