Abstract
Unstable angina and myocardial infarction are prevalent manifestations of acute coronary artery disease, combined in the term ‘acute coronary syndromes’. The introduction of sensitive markers for myocardial necrosis has led to confusion regarding the distinction between small myocardial infarctions and ‘true’ unstable angina, and the application of ever more sensitive markers has accelerated the pace at which patients with unstable angina are being re-classified to non-ST-segment elevation myocardial infarction. But in how many patients with acute chest pain is myocardial ischaemia really the cause of their symptoms? Numerous studies have shown that most have <5 ng/l high-sensitivity cardiac troponin, and that their prognosis is excellent (event rate <0.5% per year), incompatible with ‘impending infarction’. This marginalisation of patients with unstable angina pectoris should lead to the demise of this diagnosis. Without unstable angina, the usefulness of the term acute coronary syndromes may be questioned next. It is better to abandon the term altogether and revert to the original diagnosis of thrombus-related acute coronary artery disease, myocardial infarction. A national register should be the next logical step to monitor and guide the application of effective therapeutic measures and clinical outcomes in patients with myocardial infarction.
Highlights
This manuscript is based on the Wenckebach lecture, an invitational address given by the author on the occasion of the meetings of the Dutch Cardiac Society on 1 November, 2018, in Papendal, The Netherlands
Category of unstable angina was added later following the recognition that elevated levels of cardiac markers for myocardial damage were strongly associated with adverse outcomes in patients with acute chest pain [3]
While this adapted classification rightfully acknowledged the diagnostic and prognostic importance of cardiac biomarkers, the new definition led to confusion regarding the distinction between ‘small’ myocardial infarction (MI) and ‘true’ unstable angina, chest pain resulting from myocardial ischaemia in the absence of myocardial injury
Summary
Angina pectoris class IV CCS category of unstable angina was added later following the recognition that elevated levels of cardiac markers for myocardial damage were strongly associated with adverse outcomes in patients with acute chest pain [3]. While this adapted classification rightfully acknowledged the diagnostic and prognostic importance of cardiac biomarkers, the new definition led to confusion regarding the distinction between ‘small’ MIs and ‘true’ unstable angina, chest pain resulting from myocardial ischaemia in the absence of myocardial injury
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