Managing unstable angina in high-risk patients

Derek P. Chew, David J. Moliterno

Research output: Contribution to journalReview articlepeer-review


Patients with ACS should be risk-stratified based on clinical symptom complex, age, electrocardiographic ST-segment depression, and serum biochemical markers (troponin). Those who are at "high risk" should be triaged to early angiography with definition of the coronary anatomy and revascularization as indicated and feasible. Adjunctive platelet GP IIb/IIIa inhibitor therapy may be initiated "upstream" prior to coronary angiography in this patient population, particularly if symptoms are refractory to conventional therapy or in the context of an elevated serum troponin level. Substitution of enoxaparin for unfractionated heparin should be considered in these patients, based upon the growing body of data demonstrating improved outcomes with this low-molecular-weight heparin. However, its role in the context of invasive management awaits clarification. Clopidogrel may also be used early in these patients, although if this irreversible platelet inhibitor is administered prior to defining coronary anatomy, surgical revascularization may be delayed to allow a 3-5 day wash-out period. However, with the evolving evidence for LMWH and clopidogrel, the therapeutic options and combinations continue to expand, and the optimal pharmacological management across this diverse spectrum of patients will need to be individualized.

Original languageEnglish
Pages (from-to)31A-48A
JournalJournal of Invasive Cardiology
Issue numberSUPPL. A
StatePublished - 2002

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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