Risk Stratification in Patients With Unstable Angina

Abstract

Considerable progress has occurred in our understanding of the pathophysiology and therapy of unstable angina pectoris.1 2 3 Knowledge concerning the importance of plaque rupture and thrombosis formation has led to the use of intravenous heparin, aspirin, and exploration of new antiplatelet strategies in conjunction with antianginal therapy. Despite this increased understanding in the use of antithrombotic and antianginal therapy, the fear of subsequent infarction and death remains great. These fears have led to a strategy in clinically determined high-risk and many intermediate-risk patients of coronary angiography and revascularization after stabilization before or soon after hospital discharge.1 Delay in performing coronary angiography for several weeks to months because of inadequate resources has been associated with a relatively high risk of ischemic events and death.4 While a strategy of coronary angiography and revascularization (often without prior stress testing) may reduce the risk of ischemic events and death, it is nevertheless associated with an increased risk of acute complications and restenosis as well as increased cost. New strategies such as the use of stents and/or the platelet 7E3 glycoprotein 2B3A antibody hold great promise for further benefit, with a reduction in ischemic events and restenosis, but may add to cost. While the strategy of coronary angiography, revascularization, and exploration of new but expensive antithrombotic strategies is in my opinion appropriate in patients at high or intermediate risk of recurrent ischemic events, it may not be necessary in all. One of the most important challenges in the management of patients with unstable angina is risk stratification, most importantly to identify patients at low risk of subsequent ischemic events who could be treated by conventional medical therapy without the need for new and expensive antiplatelet agents and/or revascularization. Several studies have suggested that determination of biochemical markers such as myoglobin, CK-MB …