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-New perspectives in therapy of unstable angina-.

UNLABELLED
Unstable angina is a critical phase of coronary heart disease with high risk of myocardial infarction and death. Recently, major advances have been made concerning therapeutic management and risk stratification.


PATHOGENETIC MECHANISMS
Plaque rupture followed by local thrombus formation is the underlying mechanism for the majority of patients with unstable angina. The process that leads to plaque rupture is a complex sequence of events which includes local inflammatory activity. Rapid progression and vasospasm play a pathogenetic role only in a few patients. NEW THERAPEUTIC STRATEGIES: Pain relief is frequently successfully achieved by intravenous nitrates combined with betablockers. Calciumantagonists may be added, if angina persists. Prognostic improvement is achieved by platelet inhibitors, like acetylsalicylic acid or ticlopidine. In patients with persisting angina at rest platelet inhibitors should be combined with high-dose heparin. Thrombolytics have no advantage and should not be given without electrocardiographic evidence of myocardial infarction. The potential additional benefit of new glycoprotein IIb/IIIa receptor inhibitors or more potent anti-thrombins, like hirudin or hirulog, need to be further evaluated in larger trials. THERAPY CONTROL: The detection of minor myocardial cell injury by measurements of new cardiac markers like troponin T is associated with an unfavourable outcome. Troponin T may therefore serve as parameter for risk stratification in emergency rooms and control therapeutic regimens.