Network Meta-analysis of clinical efficacy of Chinese herbal injection in adjuvant treatment of unstable angina pectoris / 中国中药杂志

The present study evaluated the curative efficacy of Chinese herbal injection on unstable angina pectoris( UAP) by network Meta-analysis. The databases,including Pub Med,Cochrane Library,Web of Science,CNKI,CBM,VIP and Wanfang were searched for randomized controlled trial( RCT) of Chinese herbal injection in the treatment of UAP. All researchers independently screened the articles,extracted the data and evaluated the quality. Open BUGS and Stata were employed for the analysis of the trials that met the quality standards. Fifty-eight studies were finally included in this study,involving 20 intervention measures. In terms of the effective rate,16 injections such as Dengzhan Xixin Injection,Xuesaitong Injection and Danshen Injection combined with western medicine exhibited significant efficacy. In terms of ECG,Puerarin Injection,Ginkgo Leaf Extract and Dipyridamole Injection( GDI),Breviscapine Injection combined with western medicine were superior to western medicine. In terms of the reduction of the angina attack times,Sodium Tanshinone ⅡASulfonate Injection,GDI and Dazhu Hongjingtian Injection combined with western medicine showed better effects than western medicine. In terms of shortening the angina duration,Shenmai Injection combined with western medicine was superior to western medicine. As revealed by the results,Dengzhan Xixin Injection,Xuesaitong Injection,Danshen Injection,Breviscapine Injection,Danshen Ligustrazine Injection combined with western medicine displayed prominent curative efficacy,which were recommended for clinical application. Meanwhile,appropriate intervention measures should be selected according to individual conditions. Limited by the quality of the included trials,the conclusions still need to be further verified.

Combination of Activating Blood Circulation and Detoxifying Chinese Medicines Played an Anti-Inflammatory Role in Unstable Angina Patients after Percutaneous Coronary Intervention: A Multicenter, Open-Labeled, Randomized Controlled Trial / 中国结合医学杂志

OBJECTIVE@#To investigate the combined anti-inflammatory effect of activating blood circulation and detoxifying Chinese medicines in unstable angina (UA) patients.@*METHODS@#This study was an open-labeled, randomized controlled trial conducted in 5 centers in Beijing. A total of 154 patients were randomized into two groups at a 1:1 ratio by random numbers. Based on the conventional treatment, patients in the activating blood circulation (ABC) group were treated with Guanxin Danshen Droping Pill (, 0.4 g, thrice daily), and patients in the activating blood circulation and detoxifying (ABCD) group were treated with Guanxin Danshen Droping Pill (0.4 g, thrice daily) and Andrographis tablet (0.2 g, thrice daily) for 4 weeks. The primary outcome was the serum level of high sensitive C reaction protein (hs-CRP), and the secondary outcome index included the serum levels of tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), soluble CD40 ligand (sCD40L), thrombomodulin (TM), the score of angina pectoris, the score of blood stasis syndrome, and the score of Chinese medicine symptoms, observed at week 0 and week 4.@*RESULTS@#A total of 144 patients completed the trial (ABC group, n=70; ABCD group, n=74). There were no significant differences in the clinical baseline characteristics between the two groups. When compared with the ABC group, ABCD group showed better performance in reducing the level of inflammatory factors, especially hs-CRP (P<0.05), IL-6 (P<0.01) and TNF-α (P<0.01). In term of clinical symptoms, ABCD group played a better role in improving the scores of angina pectoris and blood stasis syndrome than ABC group (all P<0.05).@*CONCLUSIONS@#The combination of Guanxin Danshen Dropping Pill and Andrographis tablet exert significant anti-inflammatory effect on UA patients, which is superior to single Guanxin Danshen Dropping Pill. (Registration No. ChiCTR-TRC-13004072).

Effects of Danhong Injection () on Peri-Procedural Myocardial Injury and Microcirculatory Resistance in Patients with Unstable Angina Undergoing Elective Percutaneous Coronary Intervention: A Pilot Randomized Study / 中国结合医学杂志

OBJECTIVE@#To evaluate the effect of Danhong Injection (, DH) on the index of microcirculatory resistance (IMR) and myocardial injury in patients with unstable angina undergoing elective percutaneous coronary intervention (PCI).@*METHODS@#Seventy-eight patients with unstable angina were randomly divided into DH group (39 cases) and the control group (39 cases) during elective PCI. Randomization was performed using a random-number table. The DH group received DH at a dosage of 40 mL (mixed with 250 mL saline, covered by a light-proof bag, intravenous drip) during PCI and daily for 7 consecutive days, while the control group only received the same dosage of saline. Both groups received standardized treatment. The IMR and fractional flow reserve (FFR) were measured at maximal hyperemia before and after PCI. Myocardial markers, including myoglobin, creatine kinase (CK), creatine kinase MB (CK-MB), and coronary troponin T (cTnT) values were measured at baseline and 24 h after PCI.@*RESULTS@#Among the 78 patients enrolled, the baseline and procedural characteristics were similar between the two groups. There was no significant difference in pre-PCI myocardial markers and coronary physiological indexes between the two groups. However, post-PCI CK and CK-MB levels in the DH group were significantly lower than those in the control group (111.97 ± 80.97 vs. 165.47 ± 102.99, P=0.013; 13.08 ± 6.90 vs. 19.75 ± 15.49, P=0.016). Post-PCI myoglobin and cTNT-positive tend to be lower in the DH group than in the control group but did not reach statistical significance (88.07 ± 52.36 vs. 108.13 ± 90.94, P=0.52; 2.56% vs.7.69%, P=0.065). Compared with the control group, the post-IMR levels of the DH group tended to decrease, but there was no statistical difference (20.73 ± 13.15 vs. 26.37 ± 12.31, P=0.05). There were no statistical differences in post-FFR in both groups. The peri-procedural myocardial injury of the DH group was significantly lower than that of the control group (2.56% vs. 15.38%, P=0.025). During the 30-d follow-up period, no major adverse cardiovascular events occurred in either group.@*CONCLUSION@#This study demonstrated benefit of DH in reducing myocardial injury and potential preserving microvascular function in patients with unstable angina undergoing elective PCI.

Network Meta-analysis of Chinese patent medicine in treatment of unstable angina pectoris / 中国中药杂志

Network Meta-analysis was used to compare the efficacy and safety of Chinese patent medicines in the treatment of unstable angina pectoris. PubMed, Cochrane Library, CNKI, Wanfang, VIP and other databases were retrieved by computers from the establishment of the databases to June 2020. Randomized controlled trials(RCTs) of Chinese patent medicines for the treatment of unstable angina pectoris were collected. Two investigators independently screened out the literatures, and extracted data according to the inclusion and exclusion criteria. The quality of the included RCTs was evaluated according to the bias risk assessment tool recommended by the Cochrane System Reviewer Manual, and the Stata 13.0 software was used for data analysis and mapping. Through screening, 28 eligible studies were finally included, with the sample size of 2 885 cases, involving 8 Chinese patent medicines. The results of the network Meta-analysis showed that in terms of total effective rate for angina symptom improvement, the order was as follows: Shenshao Capsules > Naoxintong Capsules > Ginkgo Ketone Ester Dripping Pills > Compound Danshen Dripping Pills > Ginkgo Leaf Tablets > Shexiang Baoxin Pills > Tongxinluo Capsules > Yindan Xinnaotong Soft Capsules; in terms of total effective rate for ECG curative effect, the order was as follows: Ginkgo Ketone Ester Dripping Pills>Compound Danshen Dripping Pills > Tongxinluo Capsules > Shenshao Capsules > Shexiang Baoxin Pills > Yindan Xinnaotong Soft Capsules; in terms of hypersensitivity-C-reactive protein curative effect, the order was as follows: Tongxinluo Capsules > Shenshao Capsules > Ginkgo Leaf Tablets>Compound Danshen Dropping Pills> Shexiang Baoxin Pills > Naoxintong Capsules > Yindan Xinnaotong Soft Capsules > Ginkgo Ketone Ester Dropping Pills. Chinese patent medicine combined with conventional therapy can improve the clinical efficacy of unstable angina pectoris. Due to the differences in the quantity and quality of the included studies, the order results of Chinese patent medicines need to be further verified.

Effictiveness and safety of Xueshuantong Injection in treatment of unstable angina pectoris: a systematic review and Meta-analysis of randomized controlled trials / 中国中药杂志

To assess the effectiveness and safety of Xueshuantong Injection in the treatment of unstable angina pectoris. Literatures were retrieved in PubMed,the Cochrane Library,EMbase,the China National Knowledge Infrastructure Database( CNKI),the Chongqing VIP Chinese Science Database( VIP),the Chinese Biomedical Literature Database( Sino Med) and Wanfang Data. The time limitation ranged from the commencement of each database to April 28,2019. The assessment of ethodological quality was based on the Cochrane Handbook 5.1,and the data were analyzed by using Rev Man 5.3 software. A total of 38 RCTs involving 4 074 patients were included. The included trials were all of low quality. Xueshuantong Injection combined with routine basic treatment( RBT) was superior to RBT alone in alleviating clinical symptoms,with statistically significant differences between the groups( RR = 1. 19,95% CI[1. 15,1. 24]). Xueshuantong Injection combined with RBT was better than RBT alone in the efficiency of anginal symptom( RR = 1.23,95%CI[1.18,1.29]). Xueshuantong Injection combined with RBT reduced the consumption of nitroglycerin,which was more effectively than RBT alone,with statistically significant differences between the groups( RR = 1.64,95%CI[1.23,2.19]). Xueshuantong Injection combined with RBT decreased hs-CRP levels,which was more effectively than RBT alone,with statistically significant differences between the groups( MD =-0.48,95%CI[-0.57,-0.40]). However,there was no statistical difference between groups in the incidence of myocardial infarction. The reported adverse effects of Xueshuantong Injection were mainly dizziness,headache,itchy skin and gastrointestinal symptoms. Xueshuantong Injection combined with RBT can alleviate unstable angina pectoris. However,due to the low quality of included studies,further well-designed multicenter and large-scale RCTs are still needed to evaluate the efficacy of Xueshuantong Injection.

Gene mutations of platelet glycoproteins and response to tirofiban in acute coronary syndrome / Mutações gênicas das glicoproteínas plaquetárias e resposta ao tirofiban na síndrome coronariana aguda

CONTEXT AND OBJECTIVES: Glycoprotein inhibitors (abciximab, eptifibatide and tirofiban) are used in patients with unstable angina and non-ST-segment elevation myocardial infarction before percutaneous coronary intervention. Of these, tirofiban is the least effective. We hypothesized that the response to tirofiban might be associated with glycoprotein gene mutations. DESIGN AND SETTING: Prospective study at Emergency Unit, Heart Institute (InCor), University of São Paulo. METHOD: Intrahospital evolution and platelet aggregation in response to tirofiban were analyzed in relation to four glycoprotein mutations in 50 patients indicated for percutaneous coronary intervention: 17 (34%) with unstable angina and 33 (66%) with non-ST-segment elevation myocardial infarction. Platelet aggregation was analyzed using the Born method. Blood samples were obtained before and one hour after tirofiban infusion. Glycoproteins Ia (807C/T ), Ib (Thr/Met) , IIb (Ile/Ser ) and IIIa (PIA ) were the mutations selected. RESULTS: Hypertension, dyslipidemia, diabetes, smoking, previous coronary artery disease and stroke were similar between the groups. Mutant glycoprotein IIIa genotypes had lower platelet aggregation before tirofiban administration than that of the wild genotype (41.0% ± 22.1% versus 55.9% ± 20.8%; P = 0.035). Mutant glycoprotein IIIa genotypes correlated moderately with lower platelet inhibition (r = -0.31; P = 0.030). After tirofiban administration, platelet glycoprotein Ia, Ib, IIb and IIIa mutations did not influence the degree of inhibition of platelet aggregation or intrahospital mortality. CONCLUSIONS: Mutations of glycoproteins Ia, Ib, IIb and IIIa did not influence platelet aggregation in response to tirofiban in patients with unstable angina and non-ST-segment elevation myocardial infarction.

RESUMO CONTEXTO E OBJETIVOS: Inibidores da glicoproteína (abciximab, eptifibatide, tirofiban) são utilizados em pacientes com angina instável e infarto do miocárdio sem elevação do segmento ST (IAMSSST) antes da intervenção coronária percutânea. Dentre eles, o tirofiban é o menos eficaz. Nossa hipótese é que a resposta ao tirofiban possa estar associada a mutações no gene da glicoproteína. DESENHO E LOCAL: Estudo prospectivo na Unidade de Emergência do Instituto do Coração (InCor), Universidade de São Paulo (USP). MÉTODOS: Foram analisadas a evolução intra-hospitalar e agregabilidade plaquetária em resposta ao tirofiban de 4 mutações da glicoproteína em 50 pacientes com indicação para intervenção coronária percutânea, 17 (34%) com angina instável e 33 (66%) com IAMSSST. A agregação plaquetária foi analisada pelo método de Born. Amostras de sangue foram obtidas antes e uma hora após infusão do tirofiban. As glicoproteínas Ia (807C/T ), Ib (Thr/Met ), IIb (Ile/Ser ) e IIIa (PIA ) foram as mutações selecionadas. RESULTADOS: Hipertensão, dislipidemia, diabetes, tabagismo, doença coronariana e acidente vascular cerebral prévios foram semelhantes entre os grupos. Observou-se menor agregabilidade plaquetária dos genótipos mutantes da glicoproteína IIIa antes da administração de tirofiban do genótipo selvagem (41% ± 22% versus 56% ± 21%; P = 0,035). Genótipos mutantes da glicoproteína IIIa correlacionaram-se moderadamente com menor inibição plaquetária (r = -0,31; P = 0,030). Após a administração tirofiban, as mutações das glicoproteínas Ia, Ib, IIb, e IIIa não influenciaram o grau de inibição da agregação plaquetária e mortalidade intra-hospitalar. CONCLUSÕES: Mutações das glicoproteínas Ia, Ib, IIb e IIIa não influenciaram a agregação plaquetária em resposta ao tirofiban nos pacientes com angina instável e IAMSSST.

Acute management of unstable angina and non-ST segment elevation myocardial infarction / Tratamento atual da síndrome coronária aguda sem supradesnivelamento do segmento ST

Non-ST segment elevation coronary syndrome usually results from instability of an atherosclerotic plaque, with subsequent activation of platelets and several coagulation factors. Its treatment aims to reduce the ischemic pain, limiting myocardial damage and decreasing mortality. Several antiplatelet and anticoagulation agents have been proven useful, and new drugs have been added to the therapeutic armamentarium in the search for higher anti-ischemic efficacy and lower bleeding rates. Despite the advances, the mortality, infarction and readmission rates remain high.

A síndrome coronária sem supradesnivelamento do ST geralmente resulta da instabilização de uma placa aterosclerótica, com subsequente ativação plaquetária e de diversos fatores de coagulação. O tratamento visa aliviar a dor isquêmica, limitar o dano miocárdico e diminuir a mortalidade. Diversos agentes antiagregantes e anticoagulantes provaram sua utilidade, e novas drogas passaram a compor o arsenal terapêutico, buscando maior eficácia anti-isquêmica e menores índices de sangramento. Apesar dos avanços, as taxas de mortalidade, infarto e reinternação ainda permanecem elevadas.

Diagnóstico y tratamiento de la angina inestable aguda e infarto miocárdico sin elevación del segmento ST / Diagnosis and treatment of acute unstable angina and myocardial infarction without ST segment rise

La angina inestable aguda y el infarto miocárdico sin elevación del segmento ST son dos grandes afecciones del síndrome coronario agudo. Su frecuencia se incrementa con los novedosos y rápidos procedimientos terapéuticos que mejoran la supervivencia del paciente coronario. La presente investigación expone las clasificaciones más actuales, la fisiopatología, las causas y sus mecanismos patogénicos, los hallazgos según la coronariografía y las categorías de riesgo según los elementos clínicos, enzimáticos y electrocardiográficos cuyos marcadores contribuyen al diagnóstico y al pronóstico de ambas dolencias. Se valoran los diagnósticos diferenciales, la conducta médica y el arsenal terapéutico disponible en los distintos estadios de la angina inestable aguda, del infarto, de la angina refractaria y de Prinzmetal. Finalmente se presenta un algoritmo que resume el tratamiento en el síndrome coronario agudo sin elevación del segmento ST

The acute unstable angina and the myocardial infarction without ST segment rise are two major affections of acute coronary syndrome. Its frequency is increases with the novel and fast therapeutical procedures improving the coronary patient survival. Present research shows the more current classifications, the pathophysiology, the causes and its pathogenic mechanisms, the findings according the coronarygraphy and the risk categories according to the clinical, enzymatic and electrocardiographic elements whose markers contributing to diagnosis and prognosis of both diseases. The differential diagnoses, the medical behavior and the therapeutical armamentarium available in the different stages of the acute unstable angina, of infarction, of refractory angina and or the Prinzmetal. Finally, an algorithm summarizing the treatment of the acute coronary syndrome without ST segment rise is presented

Influence of folic acid on plasma homocysteine levels & arterial endothelial function in patients with unstable angina.

Background & objectives: High plasma homocysteine (Hcy) levels are known to be associated with coronary artery disease, but the precise level associated with an increased risk is yet controversial. Whether the beneficial effects of folic acid on arterial endothelial function persist over longer periods is not known. This study was carried out to assess whether folic acid supplementation could produce improvements in Hcy levels and arterial endothelial function in the patients with unstable angina (UA) and hyperhomocysteinaemia. Methods: The plasma Hcy levels of 52 cases with UA and 30 control subjects were measured by using high-performance liquid chromatography (HPLC) with fluorescence detection, plasma folic acid and vitamin B12 levels were also measured. The patients with hyperhomocysteinaemia were treated with 5 mg of folic acid for 8 wk, and then rechecked the plasma levels of Hcy, folic acid and vitamin B12 at the end of 4th and 8th wk. Arterial endothelial function was measured as flow-mediated dilation of the brachial artery using high-resolution B-mode ultrasound in 22 cases with UA and hyperhomocysteinaemia before and after folic acid treatment. Results: The plasma Hcy level was significant higher in the patients with UA than in the controls (19.2 ± 4.9 vs 10.7 ± 5.3 μmol/l, P<0.01). The plasma levels of folic acid and vitamin B12 were significant lower in the patients with UA than in the controls. There were 22(42.3%) patients with hyperhomocysteinaemia in UA group. After 4 and 8 wk of administration of folic acid, the Hcy level reduced by 20.3 and 55.3 per cent in the UA patients with hyperhomocysteinaemia, respectively. Flow-mediated dilation also improved significantly, from 6.4 ± 1.9 to 9.0 ± 1.2 per cent (P<0.05) after 8 wk treatment with folic acid. Interpretation & conclusions: Plasma Hcy level was elevated in patients with UA. Folic acid can reduce the plasma Hcy levels and improve arterial endothelial function in the UA patients with hyperhomocysteinaemia.

Effect of un-fractionated heparin and low molecular weight heparin on hospital mortality in patients with non ST elevation acute coronary syndrome (ACS).

BACKGROUND: The Thai ACS registry is a multi-center prospective registration that describes the epidemiology, management practices and in-hospital outcomes of patients with acute coronary syndromes. OBJECTIVE: Study the registry difference in hospital outcomes about cardiac death and length of stay between low molecular weight heparin (LMWH) and un-fractionated heparin (UFH). MATERIAL AND METHOD: This is an observational descriptive study. The authors collected data from the database of the Thai ACS registry. RESULTS: There were 233 of 3963 cases (5.9%) with cardiac death in the present study. Cardiac death in the non-ST elevated myocardial infraction (NSTEMI) group was larger than in the UA group (7.6% vs. 2.4%, p-value < 0.001). The heparin group had more cardiac death than the LMWH group (9.3% vs. 5.2%, p-value < 0.001). NSTEMI with heparin treatment had more cardiac deaths than LMWH treatment (11.8% vs. 6.8%, odd ratio 1.8). UA with heparin treatment had more cardiac deaths than LMWH treatment (4.0% vs. 2.0%, odd ratio 2.0). NSTEMI had a longer length of stay than UA (56.9% vs. 44.7%, p-value = 0.001). The heparin group had a longer stay than LMWH (58.8% vs. 51.7%, p-value < 0.001). CONCLUSION: Low molecular weight heparin had benefit over un-fractionated heparin in reduction of hospital mortality and length of stay in both unstable angina and non-ST elevation myocardial infarction.

Demographic, management practices and in-hospital outcomes of Thai Acute Coronary Syndrome Registry (TACSR): the difference from the Western world.

BACKGROUND: To establish a national registration of acute coronary syndrome (ACS) registry in Thailand by networking health service institutions to determine the demographic, management practices, and in-hospital outcomes of patients with ACS. MATERIAL AND METHOD: The Thai ACS registry is a multi-center prospective project of nationwide registration in Thailand. Institutions were invited to participate in the registry through members of the Heart Association of Thailand. A series of workshops were organized to ensure standardization and quality control of the data and conduct of the present study. Web-based double data entry was used and the data were centrally managed and analyzed. RESULTS: The enrollment of the patients started in August 2002. After three years, records of 9,373 patients were collected from 17 hospitals. The patients were classified as ST elevation myocardial infarction (STEMI) (40.9.%), non-ST-elevation myocardial infarction (NSTEMI) (37.9%) and unstable angina (UA) (21.2%). The STEMI group was younger predominantly male, with a fewer number of diabetes than NSTEMI or UA. About half of the STEMI patients (52.6%) received reperfusion therapy. Primary percutaneous coronary intervention (PCI) was performed in 22.2% of STEMI. The median door to needle and door to balloon time were 85.0 and 122 minutes respectively. The median times to treatment were 240 minutes in the thrombolysis group and 359 minutes in the primary PCI group. Nearly half of NSTEMI and UA went to coronary angiography and about one-fourth of them received revascularization either PCI or coronary artery bypass grafting in the same admission. The total mortality rate was high in STEMI (17.0%) followed by NSTEMI (13.1%) and UA (3.0%). CONCLUSION: Thai ACS registry provides a detail of demographic, management practices, and in-hospital outcomes of patients with ACS. Time from onset to admission, door to needle time and door to balloon time were considered as suboptimal. Overall, in-hospital mortality is higher than reports from Western countries. The raising awareness among the general population about urgency of seeking medical attention for chest pain and concerted effect to improve in-hospital time delay is warranted. These data may have an impact on our health care system and alert the government to adopt an appropriate policy to solve these problems.

Disminución de hemorragias totales con dosis reducidas de enoxaparina en angina inestable de alto riesgo / Estudio ENHNFAI. (ENoxaparina vs Heparina No Fraccionada en Angina inestable). Informe preliminar. Decrease of total hemorrhage with reduced doses of enoxaparin in high risk unstable angina. ENHNFAI study. (Enoxaparin vs non-fractionated heparin in unstable angina). Preliminary report

In this prospective, randomized and controlled study, we compare complications in 2 groups of patients: group 1, enoxaparin 0.8 mg/kg, subcutaneous every 12 hours during 5 days, and group 2, intravenous unfractionated heparin during 5 days, by infusion treated to activate partial tromboplastin time 1.5-2 the upper limit of normal. Blood samples were obtained at 4, 12, 24 hours and at day 5 of treatment, to measure anti-Xa levels, and also, evaluated end points at 30 days, between groups. Univariate and multivariate logistic regression analyses were performed with clinical and angiographic variables between groups, with p < 0.05. RESULTS: 203 consecutive patients, average age of 60.5 +/- 11.2 years, and 80 men, were included. There were no differences in clinical and angiographic characteristics. All patients with enoxaparin had therapeutic levels of anti-Xa, of 0.5 to 0.67 U/mL. There was increasing risk of total bleeding in group 2 (18.7) than in group 1 (5.6), with RR = 1.72 (95 CI 1.29, 2.29), p = .003. Also, there was 33.3 of MACE in group 2, and only 17.8 in group 1, with RR = 1.88 (CI 95 1.29, 2.29), p = .011. CONCLUSIONS: 1) Low doses of enoxaparine achieve therapeutic levels, since the first 4 hours of treatment. 2) A significant reduction of total bleeding occurred with the low doses of enoxaparin, with the same efficacy to reduce MACE during follow-up.

Como conduzir o paciente com diagnóstico de angina instável de baixo risco? / How to characterize the patient with low-risk unstable angina?

A angina instável encontra-se no centro de um espectro que tem como extremidades a angina do peito estável e o infarto agudo do miocárdio. Pela sua grande variedade de apresentação clínica, é indispensável classificá-la e estratificar seu risco. A angina de baixo risco representa sua apresentação mais benigna, caracterizando-se por quadro clínico frusto e ausência de alterações eletrocardiográficas e/ou enzimáticas. Sua caracterização é de fundamental importância à terapêutica adequada e ao prognóstico favorável.

Tratamento antitrombínico na angina instável e infarto agudo do miocárdio não-Q / Antithrombotic therapy on unstable angina and non-Q wave myocardial infarction

A angina instável e o infarto do miocárdio sem elevação do segmento ST têm como mecanismo desencadeante a fissura ou ruptura da placa aterosclerótica da artéria coronária responsável, seguida de espasmo e trombose superimposta. No manejo terapêutico, entre outros medicamentos utilizados, tem fundamental importância o tratamento com antitrombínico. A utilização do tratamento antitrombínico nesse grupo desenvolveu-se em ritmo acelerado nesta última década. Grandes estudos clínicos randomizados foram completados com as heparinas de baixo peso molecular e inibidores diretos da trombina. As heparinas de baixo peso molecular mostraram-se ser tão ou até mais eficazes que a heparina não-fracionada, enquanto os inibidores diretos da trombina apresentaram vantagem sobre a heparina não-fracionada na fase aguda, mas com menor benefício a longo prazo. Neste artigo, são abordadas as vantagens do tratamento com antitrombínicos de ação indireta e direta disponíveis e as perspectivas para o uso de novos antitrombínicos.

A meta-analysis of controlled clinical trials comparing low-molecular weight heparins with unfractionated heparin in unstable angina.

BACKGROUND: Unfractionated heparin has been used extensively for the treatment of unstable angina/non-Q wave myocardial infarction but it has several disadvantages. Low-molecular weight heparins are now recommended although they are 3-5 times costlier than unfractionated heparin since they are convinient to administer and do not require activated thromboplastin time monitoring. Whereas enoxaparin, a low-molecular weight heparin, has been demonstrated to be superior to unfractionated heparin, the results of other low-molecular weight heparins have not been so convincing. METHOD AND RESULTS: Through manual, MEDLINE and EMBASE search, we identified five randomized trials (excluding enoxaparin trials) that compared low-molecular weight heparins with unfractionated heparin in unstable angina. The prespecified efficacy end point of interest included a composite of death, myocardial infarction, recurrent angina and urgent revascularization. The safety end point was taken as a composite of major hemorrhage, minor hemorrhage, thrombocytopenia, allergic reaction and any other adverse event. We calculated odds ratio (95% confidence interval) for each trial for the composite end point, and the pooled odds ratio (95%) confidence interval) was calculated using two established methods of meta-analysis, the Mantel-Haenszel-Peto method and the DerSirmonian-Laird method. Both the methods yielded similar odds ratio (95% confidence interval). Separate odds ratio were calculated for efficacy and safety end points. There was a nonsignificant reduction in the incidence of the composite efficacy end point: the odds ratio (95% confidence interval) was 0.83 (0.70-0.99: p=0.08). The odds ratio (95% confidence interval) for the safety data was 0.78 (0.69-1.26: p=0.33). CONCLUSIONS: No statistically significant difference was observed when the efficacy and safety of low-molecular weight heparins were compared with those of unfractionated heparin. A cost-effectiveness analysis of low-molecular weight heparins versus unfractionated heparin must be done urgently to establish more firmly the place of low-molecular weight heparins in the management of unstable angina.

Immune response in acute coronary syndromes.

Inflammatory response in the atherosclerotic lesions of coronary artery disease, mediated by cellular immune mechanisms is well appreciated. The significance of the immuno-inflammatory processes for the development of acute ischaemic sequelae of these lesions remains unsettled. Fifty patients of acute coronary syndromes were studied for complement components and immunoglobin levels by single radial immunodiffusion method. Twenty-eight patients of acute myocardial infarction showed significantly lower levels of complement components C3 and C4 at admission (C3--69.19 +/- 12.91 mg% compared to 82.40 +/- 9.26 mg% in controls, p < 0.01; C4--14.56 +/- 2.46 mg% compared to 18.53 +/- 2.69 mg% in controls, p < 0.01). Twenty-two patients of unstable angina did not show any significant change (C3--83.14 +/- 8.01 mg% and C4--19.07 +/- 4.47 mg%). Sixteen patients of acute myocardial infarction who were thrombolysed with streptokinase showed a steep rise in the levels of complement components immediately after thrombolysis (C3--69.19 +/- 12.91 mg% before and 100.56 +/- 17.09 mg% after thrombolysis, p < 0.001; C4--14.56 +/- 2.46 mg% before and 21.48 +/- 4.78 mg% after thrombolysis, p < 0.001). Plasma C3 and C4 levels in acute myocardial infarction showed no relationship with peak CPK levels. Plasma immunoglobulins remained unchanged in patients of acute coronary syndromes.

La heparina de bajo peso molecular en la angina de pecho inestable / Low molecular weight heparin in unstable angina pectoris

Estudiamos el efecto terapéutico de la heparina estándar (HS) en comparación con el de la heparina de bajo peso molecular (HBPM) en dos grupos homogéneos de 14 pacientes, elegidos al azar, con historia clínica y signos electrocardiográficos de angina de pecho inestable (AI) tratada convencional y simultáneamente con antiagregantes plaquetarios, nitratos, bloqueadores adrenérgicos beta, si no existía contraindicación, y/o antagonista del calcio. Ambas heparinas por separado mostraron efecto terapéutico significativo sobre los síntomas y signos de la AI. Disminuyeron a cero el número y duración de la isquemia miocárdica sintomática observada en el ECG ambulatorio (ECG-Holter). En lapsos similares desaparecieron los síntomas de la angina de pecho: 51.9 ñ 20.2 min. para la HS y en 48.14 ñ 20.7 min. para la HBPM. Disminuyó la frecuencia de la isquemia miocárdica asintomática descubierta en el ECG-Holter: 9 episodios se redujeron a 4 con la HS y 8 episodios disminuyeron a 3 con la HBPM. Con la HS disminuyó la duración total de la isquemia miocárdica asintomática de 52 min a 15 min. y el promedio de la isquemia miocárdica asintomática disminuyó de 3.71 ñ 3.29 min. a 1.07 ñ 1.81 min (P < 0.01). Con la HBPM disminuyó la duración total de la isquemia miocárdica asintomática de 60 a 10 min. y el promedio de isquemia miocárdica asintomática disminuyó de 4.28 ñ 4.49 min. a 0.71 ñ 1.43 min. (P< 0.02). Después del tratamiento con ambas heparinas se redujo considerablemente la frecuencia de extrasistolia, sobre todo letal. Si bien en este estudio mostramos que no existe diferencia estadística en la acción terapéutica de las heparinas estándar y de bajo peso molecular, la HBPM redujo muy rápidamente los cuadros anginosos, redujo substancialmente tanto la isquemia miocárdica sintomática, como la asintomática y las arritmias, sobre todo extrasístoles ventricular y la taquicardia paroxística auricular. En comparación con la HS, la HBPM es de muy fácil aplicación y no tiene efectos secundarios sobre los tiempos de coagulación y sangrado