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March 12, 2001

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

Author Affiliations

From the Divisions of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio (Dr O'Rourke), Roosevelt Hospital, New York, NY (Dr Hochman), Hahnemann University Hospital, Philadelphia, Pa (Dr Cohen), and Brigham and Women's Hospital, Boston, Mass (Drs Popma and Cannon); and Prairie Cardiovascular Consultants, Ltd, Springfield, Ill (Dr Lucore). Dr O'Rourke has received research grants from Merck & Co, Inc, Pfizer & Co, Inc, DuPont Pharmaceuticals Company and Fujisawa Healthcare, Inc, and Aventis Pharmaceutical Company; Dr Hochman has received research grants from Merck & Co, Inc, Cor Therapeutics, Centocor, Inc, and Rhone-Poulenc Pharmaceutical Company; Dr Cohen has received grant and research support from Rhone-Poulenc Pharmaceutical Company; Dr Lucore has served as a consultant and participated on the speaker's bureau for Merck & Co, Inc, Eli Lilly and Company, Centocor, Inc, and Genentech, Inc, for continuing medical education programs and database studies in his institution; and Dr Cannon currently receives research grant support through the Department of Medicine of Brigham and Women's Hospital from Dade Behring, Merck & Co, Inc, Aventis Pharmaceutical Company, Bristol-Myers Squibb, and COR Therapeutics, Inc; is on the speaker bureau for Aventis Pharmaceutical Company, Bristol-Myers Squibb, Centocor, Inc, COR Therapeutics, Inc, Eli Lilly and Company, Merck & Co, Inc, and Sanofi, Inc; and has received honoraria for preparation of educational materials from Centocor, Inc, Eli Lilly and Company, Excerpta Medica, Ingenix, Inc, and Merck & Co, Inc.

Arch Intern Med. 2001;161(5):674-682. doi:10.1001/archinte.161.5.674

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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