A group of 125 patients with
unstable angina were studied over a 5-year period to define the incidence of refractory
unstable angina in the current era of 5-drug medical
therapy with intravenous
heparin,
aspirin,
nitrates,
calcium antagonists and beta blockers. All patients had greater than 20 minutes of
chest pain at rest with reversible electrocardiographic changes occurring in the absence of
myocardial infarction. Patients were considered refractory only if
chest pain continued despite treatment with maximal 5-drug
therapy. At the time of transfer to the center, 65 patients continued to have ischemic
chest pain at rest and were considered "medically refractory" by their referring physicians. A more aggressive medical regimen was used, and 54 patients (83%) were rendered
chest pain-free. Of the 11 truly refractory patients (8.8%), coronary arteriography revealed an increased likelihood of left main or 3-vessel disease (7 of 11 vs 26 of 114; p = 0.01). In-hospital treatment strategies for the 114 patients stabilized with medical
therapy included continued medical
therapy (n = 37), coronary angioplasty (n = 46) and bypass grafting (n = 31). The rate of
myocardial infarction or death in patients managed medically was 3%. Coronary angioplasty in medically stabilized patients was complicated by an abrupt closure rate of 26%, and
a 17% rate of
myocardial infarction, death or need for emergency bypass grafting. Medically stabilized patients undergoing bypass grafting had a 9% rate of
myocardial infarction or death.
Unstable angina truly refractory to current, maximal medical
therapy is infrequent (8.8%).(ABSTRACT TRUNCATED AT 250 WORDS)