INTEGRATION OF ANTICOAGULATION, THROMBOLYSIS AND CORONARY ANGIOPLASTY FOR UNSTABLE ANGINA-PECTORIS

Unstable angina pectoris remains a challenging acute ischemic syndrome to treat despite recent randomized trials that confirm the benefit of intravenous heparin. Coronary angioplasty, which is often required to treat the underlying arterial lesion, is adversely affected by the presence of thrombus with at least a 2-fold increase in abrupt closure. Four studies with heparin treatment prior to angioplasty indicate a reduction of abrupt vessel closure from 8-33% to 0-6% with apparent reduction of morbidity; no controlled trials are thus far available for heparin pretreatment. Another therapeutic alternative, thrombolytic therapy, has had quite equivocal results with several negative small studies. When angioplasty has been performed with thrombolytic therapy, a nonfibrin-specific plasminogen activator appears to be preferable. Newer studies that focus on thrombin inhibitors that bind to clot-bound thrombin and potent antiplatelet agents are in the early phase of clinical investigation. This review offers current recommendations for the integration of heparin, thrombolysis, and coronary angioplasty for unstable angina pectoris.