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New Approaches to Diagnosis and Management of Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction

Robert A. O'Rourke, MD; Judith S. Hochman, MD; Marc C. Cohen, MD; Charles L. Lucore, MD; Jeffrey J. Popma, MD; Christopher P. Cannon, MD
Arch Intern Med. 2001;161(5):674-682. doi:10.1001/archinte.161.5.674.
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Recently, it has been demonstrated in multiple clinical research studies that non–Q-wave myocardial infarction shares many of the features of unstable angina pectoris and that both diseases initially are managed similarly. Important new antiplatelet drugs (glycoprotein IIb-IIIa inhibitors) and antithrombin agents (low-molecular-weight heparin) are currently recommended for patients with unstable angina pectoris/non–ST-segment elevation MI who are at high or intermediate risk on the basis of symptoms, electrocardiographic findings, and the presence or absence of serum markers (eg, troponin I, troponin T, and creatine kinase-MB). This review provides important information concerning the results of clinical studies of glycoprotein IIb-IIIa inhibitors (tirofiban hydrochloride and eptifibatide) when used with unfractionated heparin in patients with this syndrome or with low-molecular weight heparin (enoxaparin sodium) in similar patients. The Thrombolysis in Myocardial Infarction IIIB, Veterans Affairs Non–Q-Wave Infarction Studies in Hospital, and Fast Revascularization During Instability in Coronary Artery Disease II studies evaluating a conservative, ischemia-guided approach vs an early aggressive approach to such patients are presented, with a practical algorithm for treating such patients.

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Figure 1.

Algorithm for the assessment of patients presenting with chest pain and suspected or definite coronary artery disease. MI indicates myocardial infarction; ECG, electrocardiogram; CK-MB, creatine kinase-MB fraction; SX, symptoms; CHD Pt, patients with coronary heart disease; and ACS protocol, acute coronary syndrome protocol for patients with unstable angina or non–ST-segment elevation myocardial infarction. Stress testing indicates pharmacological stress testing (adenosine diphosphate or dipyridamole) with myocardial perfusion imaging, or dobutamine echocardiography.

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Figure 2.

Algorithm for treating patients with acute coronary syndromes of unstable angina or non–ST-segment elevation myocardial infarction (MI). UFH indicates unfractionated heparin; Gp, glycoprotein; LMW, low-molecular-weight; PCI, percutaneous coronary intervention; and ACE-I, angiotensin-converting enzyme inhibitors. Plus sign indicates evidence of high-risk ischemia on exercise treadmill testing or pharmacological stress imaging.

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