Unstable angina — experience with surgical therapy in the subset of patients having preinfarction angina

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During the first 10 years of direct cardiac revascularization by coronary bypass surgery a number of indications for such therapy have been presented for consideration to the medical community; and after an appropriate clinical experience has evolved, they generally have been accepted or discarded. Thus a number of urgent or emergent indications for surgery have been defined, primarily in relation to or associated with mechanical complications occurring after a myocardial infarction.

This sequence has not pertained in regard to the role of revascularization in patients experiencing acute ischemic manifestations of coronary artery disease. Much of the debate that has evolved has been semantic, but much of it has been due initially to disparate surgical experience and later to continually improving medical management. This presentation will be confined to that subgroup of patients with emergent indications for surgery that we feel can appropriately be termed “preinfarction angina.”


The hallmark of these cases has been a short history of crescendo angina with episodes lasting 15 minutes or more of either recent onset or representing an exacerbation of a previously stable anginal pattern associated with evanescent S-T segment or T-wave changes of ischemia, and continuing to occur at rest under medical therapy in the hospital. Initially no Q-waves are present in the electrocardiogram and enzymes are within 10% of normal. Medical therapy has included the use of nitrates, sedatives, tranquilizers, and propranolol in doses up to 120 mg a day when appropriate; in some cases after-load reduction with frequent sublingual isosorbide dinitrate, . . .



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