Sami Shehzad, Willerson James T
Department of Cardiology, Texas Heart Institute, St. Luke's Episcopal Hospital, The University of Texas Medical School, Houston, Texas 77030, USA.
Tex Heart Inst J. 2010;37(3):262-75.
In Part 1 of this review, we discussed how plaque rupture is the most common underlying cause of most cases of unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI) and how early risk stratification is vital for the timely diagnosis and treatment of acute coronary syndromes (ACS). Now, in Part 2, we focus on the medical therapies and treatment strategies (early conservative vs early invasive) used for UA/NSTEMI. We also discuss results from various large randomized controlled trials that have led to the contemporary standards of practice for, and reduced morbidity and death from, UA/NSTEMI. In summary, ACS involving UA/NSTEMI is associated with high rates of adverse cardiovascular events, despite recent therapeutic advances. Plaque composition and inflammation are more important in the pathogenesis of ACS than is the actual degree of arterial stenosis. As results from new trials challenge our current practices and help us develop the optimal treatment strategy for UA/NSTEMI patients, the cornerstones of contemporary treatment remain early risk stratification and aggressive medical therapy, supplemented by coronary angiography in appropriately selected patients. An early-invasive-treatment strategy is of most benefit to high-risk patients, whereas an early-conservative strategy is recommended for low-risk patients. Adjunctive medical therapy with acetylsalicylic acid, clopidogrel or another adenosine diphosphate antagonist, glycoprotein IIb/IIIa inhibitors, and either low-molecular-weight heparin or unfractionated heparin, in the appropriate setting, further reduces the risk of ischemic events secondary to thrombosis. Short- and long-term inhibition of platelet aggregation should be achieved by appropriately evaluating the risk of bleeding complications in these patients.
在本综述的第1部分中，我们讨论了斑块破裂是大多数不稳定型心绞痛/非ST段抬高型心肌梗死（UA/NSTEMI）病例最常见的潜在病因，以及早期风险分层对于急性冠状动脉综合征（ACS）的及时诊断和治疗至关重要。现在，在第2部分中，我们重点关注用于UA/NSTEMI的药物治疗和治疗策略（早期保守治疗与早期侵入性治疗）。我们还讨论了各种大型随机对照试验的结果，这些结果促成了UA/NSTEMI的当代实践标准，并降低了其发病率和死亡率。总之，尽管最近治疗取得了进展，但涉及UA/NSTEMI的ACS仍与高心血管不良事件发生率相关。在ACS的发病机制中，斑块成分和炎症比动脉狭窄的实际程度更重要。由于新试验的结果挑战了我们当前的做法，并帮助我们为UA/NSTEMI患者制定最佳治疗策略，当代治疗的基石仍然是早期风险分层和积极的药物治疗，并在适当选择的患者中辅以冠状动脉造影。早期侵入性治疗策略对高危患者最有益，而对于低危患者则推荐早期保守策略。在适当的情况下，联合使用乙酰水杨酸、氯吡格雷或其他二磷酸腺苷拮抗剂、糖蛋白IIb/IIIa抑制剂以及低分子量肝素或普通肝素进行药物治疗，可进一步降低血栓形成继发缺血事件的风险。应通过适当评估这些患者出血并发症的风险来实现血小板聚集的短期和长期抑制。
