Unstable angina non ST elevation myocardial infarction overview: Difference between revisions

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==The Spectrum of Acute Coronary Syndromes==
==The Spectrum of Acute Coronary Syndromes==
*[[Acute coronary syndrome]]s ([[ACS]]) is a term that encompasses:
*[[Acute coronary syndrome]]s ([[ACS]]) is a term that encompasses:
:*[[unstable angina]] ([[UA]]),  
:*[[Unstable angina]] ([[UA]]),  
:*[[non-ST-segment elevation myocardial infarction]] ([[NSTEMI]]) and  
:*[[Non-ST-segment elevation myocardial infarction]] ([[NSTEMI]]) and  
:*[[ST-segment elevation myocardial infarction]] ([[STEMI]]).   
:*[[ST-segment elevation myocardial infarction]] ([[STEMI]]).   


Line 15: Line 15:
:*If an EKG is performed at the time that a [[non-occlusive thrombus]] is formed, it may or may not show signs of [[ischemia]](see [[Unstable angina / NSTEMI ECG|Electrocardiogram]]).   
:*If an EKG is performed at the time that a [[non-occlusive thrombus]] is formed, it may or may not show signs of [[ischemia]](see [[Unstable angina / NSTEMI ECG|Electrocardiogram]]).   


*Frequently, [[Unstable Angina]] and [[NSTEMI]] are indistinguishable on inital evaluation as these two conditions are at different spectrums of [[ischemia]].  If the ischemia is significant to cause myocardial damage, there will be an elevation of Cardiac biomarkers ([[CK-MB]] or [[troponin]]) and would be classified as an [[NSTEMI]](see [[Unstable angina / NSTEMI bio markers|Biomarkers]]).  Often, these may not be detected for up to 12 hours in the bloodstream, which emphasizes the need for thorough evaluation. <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>  
*Frequently, [[Unstable Angina]] and [[NSTEMI]] are indistinguishable on inital evaluation as these two conditions are at different spectrums of [[ischemia]].  If the ischemia is significant to cause myocardial damage, there will be an elevation of Cardiac biomarkers ([[CK-MB]] or [[troponin]]) and would be classified as an [[NSTEMI]](see [[Unstable angina / NSTEMI bio markers|Biomarkers]]).  Often, these may not be detected for up to 12 hours in the bloodstream, which emphasizes the need for thorough evaluation. <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>


==Definition==
==Definition==

Revision as of 00:28, 17 November 2012

Acute Coronary Syndrome Main Page

Unstable angina / NSTEMI Microchapters

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Overview

Classification

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Unstable Angina
Non-ST Elevation Myocardial Infarction

Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders

Epidemiology and Demographics

Risk Stratification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Varun Kumar, M.B.B.S; Lakshmi Gopalakrishnan, M.B.B.S.; Cafer Zorkun, M.D., Ph.D. [2]; Neil Gheewala, M.D. [3]; Smita Kohli, M.D.

The Spectrum of Acute Coronary Syndromes

  • Unstable angina, NSTEMI and STEMI are distinguished pathophysiologically as to whether or not the thrombus is occlusive (as in the case of STEMI) or non-occlusive(as in the case of UA and NSTEMI).
  • Frequently, Unstable Angina and NSTEMI are indistinguishable on inital evaluation as these two conditions are at different spectrums of ischemia. If the ischemia is significant to cause myocardial damage, there will be an elevation of Cardiac biomarkers (CK-MB or troponin) and would be classified as an NSTEMI(see Biomarkers). Often, these may not be detected for up to 12 hours in the bloodstream, which emphasizes the need for thorough evaluation. [1] [2]

Definition

Unstable Angina (UA): Angina pectoris is classified as stable when its characteristics are unchanged for 60 days. Stable angina pectoris usually responds to sublingual nitroglycerin or rest. Unstable angina occurs at rest and may not improve with rest.

Unstable angina[3] [4] [5] [6] [7] [8] [9] [10] [11] [1] [2] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94] is defined as new onset angina pectoris (or chest pain which is ischemic in origin) with the following features:

  • occurs at rest or with lesser degrees of exertion than stable angina,
  • lasts less than 30minutes,
  • follows a crescendo pattern (i.e., occurs more frequently than previous)
  • there no sign of myocardial necrosis unlike in STEMI or NSTEMI, and there is no release of biomarkers of myonecrosis (CK or troponin).

Non-ST Elevation MI (NSTEMI):

Incidence

Pathophysiology

These conditions are characterized by an inadequate blood supply to meet the oxygen and metabolic demands of the myocardium.

  • The most common cause of UA/NSTEMI is reduced myocardial perfusion that results from coronary artery narrowing caused by a thrombus that developed on a disrupted atherosclerotic plaque and is usually nonocclusive.
  • Arterial inflammation which activates the macrophages and T lymphocytes located at the shoulder of a plaque increase the expression of enzymes such as metalloproteinases that cause thinning and disruption of the plaque, which in turn can lead to UA/NSTEMI.
  • An occlusive thombus or plaque can also cause this syndrome in the presence of extensive collateral supply.
  • Secondary UA can occur in conditions that increase myocardial oxygen requirements(such as fever, tachycardia or thyrotoxicosis), reduce coronary blood flow(such as hypotension) or reduce myocardial oxygen delivery(such as anemia or hypoxemia).
  • A less common cause of UA is Prinzmetal angina where in a there is focal spasm of a segment of an epicardial coronary artery caused by smooth muscle hypercontractility and/or endothelial dysfunction resulting in dynamic obstruction.
  • Some patients with progressive atherosclerosis or with restenosis after a PCI can also cause UA by severe narrowing without spasm or thrombus.

Presentation and Diagnosis

UA can have typical or atypical presentations. The 3 classic forms of presentation are:

  • Rest angina(angina commencing when the patient is at rest)
  • New onset (less than 2 months) severe angina(at least CCS class II),or
  • Increasing angina-previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by 1 or more CCS class to at least CCS class III severity)

NSTEMI generally presents as prolonged, more intense rest angina or angina equivalent.

  • Patients with suspected ACS must be evaluated rapidly.
  • Evaluation should not be done over the phone but in person and in a place where a 12 lead ECG can be obtained.
  • A focused history, examination, ECG and cardiac biomarkers are helpful to determine where the patient will be managed and whether the patient needs to be transferred or referred to a different hospital/setting.
  • Physical examination should focus on identifying the precipitating factors, comorbid conditions, rule out alternative diagnosis and assess hemodynamic status of the patient.

Unstable angina is associated with negative cardiac biomarkers whereas NSTEMI is associated with elevated cardiac biomarkers. Depending on the patient's symptoms and degree of suspicion for ACS, early coronary angiography can be performed to make a definitive diagnosis.

Risk stratification

  • Patients with UA have lower short term mortality than NSTEMI or STEMI.
  • Early risk stratification is, therefore, recommended and is based on the initial history, physical exam, ECG, assessment of renal function and cardiac biomarkers.
  • Various models to calculate risk score and determine prognosis are available for example TIMI score, PURSUIT risk model, GRACE risk score etc. This evaluation is helpful in selecting the site of care and type of therapy.
  • Physician should document their opinion of the likelihood of ACS in one of the three categories of low, intermediate or high likelihood. Patients with high risk score and/or hemodynamic instability should be managed in coronary care unit while those with intermediate to low risk score and hemodynamic stability can be managed in a step down unit.
  • A continuous ECG monitoring(telemetry) should be used to monitor for arrythmias.

Treatment

Immediate management is directed towards relief of chest pain.

  • Nitrates, ASA and morphine are recommended to control the symptoms from possible ACS.
  • Beta blockers, thienopyridines(like Clopidogrel and prasugrel) should be administered in the absence of contraindication to their use.
  • Based on the suspicion for likelihood of ACS, anticoagulants and GP IIb/IIIa inhibitors can be started early in the course of presentation.
  • Two strategies in the treatment are early invasive or conservative strategies. Most trials have shown benefit of early invasive therapy with cardiac catheterization and revascularisation procedures. Early invasive therapy is now recommended for patients with UA/NSTEMI and ST segment changes at presentation and/or positive troponins during first 24hrs of presentation.

Discharge care

  • Discharge care after UA/NSTEMI must include a medication reconciliation of inpatient and discharge medications, life style modification counselling and instructions on smoking cessation, cardiac rehabilitation and arrangements for follow-up.
  • Patients with UA/NSTEMI diagnosis should be discharged home on an ASA, clopidogrel, beta blocker, nitrates, ACE inhibitors and statins, unless contraindicated.
  • Cardiac rehab has been shown to improve exercise tolerance, improve patient compliance and assist in lifestyle modification and all patient should be referred for this.
  • Both patient and family should be informed about the treatment plan and a what to do if symptoms recur.

See Also

References

  1. ↑ 1.0 1.1 1.2 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). Circulation 2007 116: e148 – e304. PMID 17679616
  2. ↑ 2.0 2.1 2.2 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738
  3. ↑ Ambrose JA, Winters SL, Stern A, et al: Angiographic morphology and the pathogenesis of unstable angina pectoris. J Am Coll Cardiol 1985 Mar; 5(3): 609-16. PMID 3973257
  4. ↑ Crea F, Biasucci LM, Buffon A, Liuzzo G, Monaco C, Caligiuri G, et al. Role of inflammation in the pathogenesis of unstable coronary artery disease. Am J Cardiol 1997; 80: 10-6E. PMID 9296463
  5. ↑ Biasucci LM, Colizzi C, Rizzello V, Vitrella G, Crea F, Liuzzo G. Role of inflammation in the pathogenesis of unstable coronary artery diseases. Scand J Clin Lab Invest Suppl 1999; 230: 12-22 PMID 10389197
  6. ↑ Asher CR, Topol EJ, Moliterno DJ, et al: Insights into the pathophysiology of atherosclerosis and prognosis of black Americans with acute coronary syndromes. Am Heart J 1999 Dec; 138(6 Pt 1): 1073-81 PMID 10577437
  7. ↑ Fuster V, Moreno PR, Fayad ZA, Corti R, Badimon JJ. Atherothrombosis and high-risk plaque: part I: evolving concepts. J Am Coll Cardiol. 2005 Sep 20;46(6):937-54. PMID 16168274
  8. ↑ Braunwald E: Unstable angina: A classification. Circulation 1989; 80: 410-414. PMID 2752565
  9. ↑ Scirica BM, Cannon CP, McCabe CH, et al: Prognosis in the Thrombolysis in Myocardial Ischemia III Registry according to the Braunwald unstable angina pectoris classification. Am J Cardiol 2002; 90: 821-826.PMID 12372567
  10. ↑ Davies MJ: The composition of coronary-artery plaques. N Engl J Med 1997; 336:1312-1314. PMID 9113937
  11. ↑ Kennon S, Price CP, Mills PG, et al: The central role of platelet activation in determining the severity of acute coronary syndromes. Heart 2003; 89:1253-1254. PMID 12975438
  12. ↑ Kaski JC: Rapid coronary artery disease progression and angiographic stenosis morphology. Ital Heart J 2000; 1:21-25. PMID 10868918
  13. ↑ van't Hof AW, de Vries ST, Dambrink JH, et al: A comparison of two invasive strategies in patients with non-ST elevation acute coronary syndromes: Results of the Early or Late Intervention in unStable Angina (ELISA) pilot study. 2b/3a upstream therapy and acute coronary syndromes. Eur Heart J 2003; 24:1401-1405. PMID 12909068
  14. ↑ Ryan JW, Peterson ED, Chen AY, et al: Optimal timing of intervention in non-ST-segment elevation acute coronary syndromes: Insights from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Registry. Circulation 2005; 112:3049-3057. PMID 16275863
  15. ↑ Prinzmetal M, Kennamer R, Merliss R, et al: A variant form of angina pectoris. Am J Med 1959; 27:375. PMID 14434946
  16. ↑ Roe MT, Harrington RA, Prosper DM, et al: Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease. The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 2000; 102:1101-1106. PMID 10973837
  17. ↑ Lindahl B, Diderholm E, Lagerqvist B, et al: Mechanisms behind the prognostic value of troponin T in unstable coronary artery disease: A FRISC II substudy. J Am Coll Cardiol 2001; 38:979-986. PMID 11583868
  18. ↑ Roffi M, Chew DP, Mukherjee D, et al: Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation 2001; 104:2767-2771. PMID 11733392
  19. ↑ Westerhout CM, Fu Y, Lauer MS, et al: Short- and long-term risk stratification in acute coronary syndromes: The added value of quantitative ST-segment depression and multiple biomarkers. J Am Coll Cardiol 2006; 48:939-947. PMID 16949483
  20. ↑ Heeschen C, Hamm CW, Bruemmer J, Simoons ML, for the Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial (CAPTURE) Investigators : Predictive value of C-reactive protein and troponin T in patients with unstable angina: A comparative analysis. J Am Coll Cardiol 2000; 35:1535-1542. PMID 10807457
  21. ↑ Lindmark E, Diderholm E, Wallentin L, Siegbahn A: Relationship between interleukin 6 and mortality in patients with unstable coronary artery disease: Effects of an early invasive or noninvasive strategy. JAMA 2001; 286:2107-2113. PMID 11694151
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  23. ↑ Zairis MN, Papadaki OA, Manousakis SJ, et al: C-reactive protein and multiple complex coronary artery plaques in patients with primary unstable angina. Atherosclerosis 2002; 164:355-359. PMID 12204808
  24. ↑ Mueller C, Neumann FJ, Roskamm H, et al: Women do have an improved long-term outcome after non-ST-elevation acute coronary syndromes treated very early and predominantly with percutaneous coronary intervention: A prospective study in 1450 consecutive patients. J Am Coll Cardiol 2002; 40:245-250. PMID 12106927
  25. ↑ Brennan ML, Penn MS, Van Lente F, et al: Prognostic value of myeloperoxidase in patients with chest pain. N Engl J Med 2003; 349:1595-1604. PMID 14573731
  26. ↑ Buffon A, Biasucci LM, Liuzzo G, et al: Widespread coronary inflammation in unstable angina. N Engl J Med 2002; 347:5-12. PMID 12097534
  27. ↑ Gibson CM, Pinto DS, Murphy SA, et al: Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality. J Am Coll Cardiol 2003; 42:1535-1543. PMID 14607434
  28. ↑ Boersma E, Pieper KS, Steyerberg EW, et al: Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. Circulation 2000; 101:2557-2567. PMID 10840005
  29. ↑ Antman EM, Cohen M, Bernink PJ, et al: The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284:835-842. PMID 10938172
  30. ↑ Granger CB, Goldberg RJ, Dabbous O, et al: Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003; 163:2345-2353. PMID 14581255
  31. ↑ Gottlieb SO, Weisfeldt ML, Ouyang P, et al: Effect of the addition of propranolol to therapy with nifedipine for unstable angina: A randomized, double-blind, placebo-controlled trial. Circulation 1986; 73:331-337. PMID 3510764
  32. ↑ The Holland Interuniversity Nifedipine/Metoprolol Trial (HINT) Research Group : Early treatment of unstable angina in the coronary care unit: A randomised, double blind, placebo controlled comparison of recurrent ischaemia in patients treated with nifedipine or metoprolol or both. Br Heart J 1986; 56:400-413. PMID 2878675
  33. ↑ Theroux P, Ouimet H, McCans J, et al: Aspirin, heparin or both to treat unstable angina. N Engl J Med 1988; 319: 1105-1111.1998 PMID 3050522
  34. ↑ Topol EJ, Easton D, Harrington RA, et al: Randomized, double-blind, placebo-controlled, international trial of the oral IIb/IIIa antagonist lotrafiban in coronary and cerebrovascular disease. Circulation 2003; 108:` 399-406. PMID 12874182
  35. ↑ Peters RJ, Mehta SR, Fox KA, et al: Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: Observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation 2003; 108:1682-1687. PMID 14504182
  36. ↑ Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators : Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345:494-502. PMID 11519503
  37. ↑ Yusuf S, Mehta SR, Zhao F, et al: Early and late effects of clopidogrel in patients with acute coronary syndromes. Circulation 2003; 107:966-972. PMID 12600908
  38. ↑ Montalescot G, Sideris G, Meuleman C, et al: A randomized comparison of high clopidogrel loading doses in patients with non-ST-segment elevation acute coronary syndromes: The ALBION (Assessment of the Best Loading Dose of Clopidogrel to Blunt Platelet Activation, Inflammation, and Ongoing Necrosis) trial. J Am Coll Cardiol 2006; 48:931-938. PMID 16949482
  39. ↑ Neumann FJ, Kastrati A, Pogatsa-Murray G, et al: Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: A randomized controlled trial. JAMA 2003; 290:1593-1599. PMID 14506118
  40. ↑ Patti G, Colonna G, Pasceri V, et al: Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: Results from the ARMYDA-2 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study. Circulation 2005; 111:2099-2106. PMID 15750189
  41. ↑ Wiviott SD, Antman EM, Gibson CM, et al: Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: Design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38). Am Heart J 2006; 152:627-635. PMID 16996826
  42. ↑ Giugliano RP, Newby LK, Harrington RA, et al: The early glycoprotein IIb/IIIa inhibition in non-ST-segment elevation acute coronary syndrome (EARLY ACS) trial: A randomized placebo-controlled trial evaluating the clinical benefits of early front-loaded eptifibatide in the treatment of patients with non-ST-segment elevation acute coronary syndrome—study design and rationale. Am Heart J 2005; 149:994-1002. PMID 15976780
  43. ↑ Eikelboom JW, Anand SS, Malmberg K, et al: Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: A meta-analysis. Lancet 2000; 355:1936-1942. PMID 10859038
  44. ↑ Rich JD, Maraganore JM, Young E, et al: Heparin resistance in acute coronary syndromes. J Thromb Thrombolysis 2007; 23:93-100. PMID 17221324
  45. ↑ Warkentin TE, Kelton JG: Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med 2001; 344:1286-1292 PMID 11320387
  46. ↑ Petersen JL, Mahaffey KW, Hasselblad V, et al: Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-segment elevation acute coronary syndromes: A systematic overview. JAMA 2004; 292:89-96. PMID 15238596
  47. ↑ Ferguson JJ, Califf RM, Antman EM, et al: Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: Primary results of the SYNERGY randomized trial. JAMA 2004; 292:45-54. PMID 15238590
  48. ↑ Michalis LK, Katsouras CS, Papamichael N, et al: Enoxaparin versus tinzaparin in non-ST-segment elevation acute coronary syndromes: The EVET trial. Am Heart J 2003; 146:304-310. PMID 12891200
  49. ↑ Yusuf S, Mehta SR, Chrolavicius S, et al: Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med 2006; 354:1464-1476. PMID 16537663
  50. ↑ Stone GW, McLaurin BT, Cox DA, et al: Bivalirudin for patients with acute coronary syndromes. N Engl J Med 2006; 355:2203-2216. PMID 17124018
  51. ↑ FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators : Invasive compared with non-invasive treatment in unstable coronary artery disease: FRISC II prospective randomised multicentre study. Lancet 1999; 354:708-715. PMID 10475181
  52. ↑ Fox KA, Goodman SG, Klein W, et al: Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2002; 23:1177-1189. PMID 12127920
  53. ↑ Lagerqvist B, Husted S, Kontny F, et al: 5-year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation acute coronary syndrome: A follow-up study. Lancet 2006; 368:998-1004 PMID 16980115
  54. ↑ Mahoney EM, Jurkovitz CT, Chu H, et al: Cost and cost-effectiveness of an early invasive versus conservative strategy for the treatment of unstable angina and non-ST elevation myocardial infarction. JAMA 2002; 288:1851-1858. PMID 12377083
  55. ↑ Fox KA, Poole-Wilson PA, Henderson RA, et al: Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: The British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina. Lancet 2002; 360:743-751. PMID 12241831
  56. ↑ Fox KAA, Poole-Wilson P, Clayton TC, et al: 5-Year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: The British Heart Foundation RITA 3 randomised trial. Lancet 2005; 366:914-920. PMID 16154018
  57. ↑ van't Hof AW, de Vries ST, Dambrink JH, et al: A comparison of two invasive strategies in patients with non-ST elevation acute coronary syndromes: Results of the Early or Late Intervention in unStable Angina (ELISA) pilot study. 2b/3a upstream therapy and acute coronary syndromes. Eur Heart J 2003; 24:1401-1405. PMID 12909068
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  59. ↑ Ryan JW, Peterson ED, Chen AY, et al: Optimal timing of intervention in non-ST-segment elevation acute coronary syndromes: Insights from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Registry. Circulation 2005; 112:3049-3057. PMID 16275863
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