Elevated Death Risk After Heart Attack

Risk of Sudden Cardiac Death Rises Greatly Within Month After Heart Attack

Heart attack patients face the highest risk of dying from sudden cardiac death within the first month after heart attack.

That's according to a new study by researchers from the Veterans Affairs Medical Center and Mayo Clinic in Minnesota. The study appears in the Nov. 5 issue of TheJournal of the American Medical Association.

Since 1997, the risk of sudden cardiac death has steeply declined. Even so, it still causes about 325,000 adult deaths each year in the U.S., all linked to complications from heart attacks.

Sudden cardiac death occurs when the heart's electrical system fails. The heart begins beating extremely fast, preventing the ventricles from allowing enough blood to flow throughout the body. Without blood going to the brain and other vital organs, a person quickly loses consciousness and soon dies.

To better understand this problem, as well as the impact of recurrent ischemia (an inadequate flow of blood to a part of the heart) and heart failure on sudden cardiac death, the researchers studied 2,997 residents who survived a heart attack in Olmsted County, Minn., between 1979 and 2005. On average, the patients were 67 years old, and 59% of them were men.

The researchers monitored the patients through their medical records until the time of their death or through the final follow-up in February 2008.

During this time, 1,160 patients died, with 282 of these deaths caused by sudden cardiac death. The rate of sudden cardiac death for patients who had suffered a heart attack within 30 days was four times higher than that seen in the general population. For each following year, however, the rate of sudden cardiac death was lower than expected.

The researchers also found that recurrent ischemia was not associated with sudden cardiac death. However, patients who experienced heart failure during the follow-up period had more than a fourfold risk of experiencing sudden cardiac death than the general population. This translates into an absolute increase in sudden cardiac death risk of 2.5% within 30 days of a heart attack and in each year thereafter.

"The risk of sudden cardiac death is the highest during the first month after myocardial infarction, when it markedly exceeds the rate in the general population," the authors conclude. "Among 30-day survivors, the risk of sudden cardiac death declines rapidly but it is markedly increased by the occurrence of heart failure during follow-up."

In other words, it's important to continue to monitor heart attack patients long after the initial incident because dire complications can still occur long after the initial heart attack episode.

On a positive note, the researchers noted an overall 40% decline in the incidence of sudden cardiac death over the course of the study, parallel with the major changes in treatment of heart attack survivors during this time.

Allergy medications: Know your options

Because you can't always avoid allergy triggers, you may need medication to help alleviate allergy symptom

Allergy medications are available in pill, liquid, nasal spray, eyedrop and skin cream (topical) forms. Some are available over-the-counter while others are available by prescription only.

The best medication or combination of medications for you depends on your symptoms, what other health conditions you have and what other medications you take. Certain allergy medications work better for some people than others. You may need to try a few different medications to determine which ones are most effective and have the least bothersome side effects.

To choose the best allergy medications for you, learn what's available to treat your symptoms — and work with your doctor to figure out what medications is best for you.

Corticosteroids

Type	Purpose	Side effects
Nasal sprays Examples include: Beclomethasone (Beconase) Fluticasone (Flonase) Triamcinolone (Nasacort) Budesonide (Rhinocort) Flunisolide (Nasarel) Mometasone (Nasonex)	These prescription medications prevent and relieve allergy symptoms such as nasal stuffiness, sneezing, and itchy, runny nose. For many people, these nasal sprays are the most effective treatment for allergy symptoms caused by hay fever or pets. It may take a few days or longer of regular use before your symptoms improve. Nasal corticosteroids are generally safe for extended use.	Mild side effects can include: Unpleasant smell or taste Irritation, especially during the winter Crusting and nosebleeds, especially in the winter
Eyedrops Examples include: Dexamethasone (Decadron, Maxidex, others) Fluorometholone (FML, Fluor-Op, others) Prednisolone (Pred Forte, Econopred, others)	Corticosteroid eyedrops are prescription medications used to treat severe allergy symptoms such as red, watery and itchy eyes caused by hay fever and allergic conjunctivitis. They are used for only a short period of time when other types of eyedrops don't work. You may be advised to avoid these medications if you are pregnant or plan to become pregnant.	These medications can cause: Blurred vision and other mild side effects Increased risk of eye infections, glaucoma and cataracts with prolonged use
Skin creams Examples include: Hydrocortisone (Cortaid, Ala-cort, others) Triamcinolone (Triderm, Kenalog, others)	These medications relieve the scaling and itching caused by eczema (atopic dermatitis). Some low-potency corticosteroid creams are available without a prescription, but you should always talk to your doctor before using any topical corticosteroid.	Side effects can include: Skin irritation Skin discoloration
Pills and liquids Examples include: Prednisone (Prednisone, Prednisone Intensol, others) Prednisolone (Prednisolone, Prelone, others)	Oral corticosteroids are sometimes used to treat severe allergy symptoms. Because they can cause serious side effects, they're usually prescribed for only short periods of time.	Long-term use of these medications can cause serious side effects such as: Cataracts Osteoporosis Muscle weakness

Leukotriene modifiers

Type	Purpose	Side effects
Pills and tablets Leukotriene modifiers are available only by prescription. They're produced in pill and chewable tablet form. Examples include: Montelukast (Singulair) Zileuton (Zyflo) Zafirlukast (Accolate)	These drugs block the effects of leukotrienes, inflammatory chemicals released by your immune system during an allergic reaction. Such medications have proved most effective in treating asthma, but montelukast also relieves hay fever symptoms.	Side effects differ for each type of leukotriene inhibitor, but can include: Cough Dizziness Headache Stomach upset or pain Stuffy nose Tiredness Insomnia Muscle weakness Liver damage (zileuton)

Cromolyn and mast cell stabilizers

Type	Purpose	Side effects
Nasal spray Available over-the-counter, the nasal spray cromolyn sodium (examples include NasalCrom, Children's NasalCrom) works best when you take it before your symptoms develop. Some people need to use the spray three or four times a day.	Mast cell stabilizer nasal sprays prevent the release of the symptom-triggering chemical histamine. They reduce symptoms associated with hay fever and allergic conjunctivitis.	This medication can cause minor side effects, which include: Unpleasant taste Drowsiness Headache Nasal irritation Sneezing
Eyedrops Several different mast cell stabilizer eyedrops are available by prescription. None are sold over-the-counter. Examples include: Cromolyn sodium (Crolom) Lodoxamide (Alomide) Pemirolast (Alamast) Nedocromil (Alocril)	Mast cell stabilizer eyedrops prevent the release of the symptom-triggering chemical histamine. They reduce symptoms associated with hay fever and allergic conjunctivitis.	Cromolyn sodium and lodoxamide can cause: Burning or stinging eyes Rarely, other side effects Pemirolast may cause: Chills Coughing and sneezing Sore throat Nedocromil may cause side effects including: Blurred vision Changes in color vision Breathing problems or wheezing Insomnia Eye irritation or swelling Headache Increased sensitivity of eyes to sunlight Nasal congestion

Injectable epinephrine: First aid for severe allergic reactions

If you're highly allergic to certain foods, such as peanuts, or to bee or wasp venom, you may be at risk of anaphylactic shock — a sudden, life-threatening allergic reaction. To be on the safe side, your doctor may suggest that you carry an injectable dose of epinephrine (adrenaline). Epinephrine can help slow the reaction while you seek emergency medical treatment. You may be able to administer the drug by yourself, after being taught how to use a self-injecting syringe and needle. A friend, family member or medical professional called in response to a severe anaphylactic reaction also may administer the medication.

Work with your doctor

By understanding how allergy medications work, you can work with your doctor to develop a treatment plan that's best for you. Before taking any medication — prescription or over-the-counter — be sure to tell your doctor if you are pregnant or breast-feeding, if you have any chronic health problems such as diabetes, glaucoma or high blood pressure, or if you're taking any other medications. This will help you avoid a drug interaction or other adverse effect.

Keep track of your symptoms, when you use your medications, and how much you use — that way you and your doctor can figure out what works best. It may not be possible for you to avoid allergy symptoms altogether — but working with your doctor to find the right medications can help.

Blood cholesterol level and its sequele

What Your Cholesterol Levels Mean

Your test report will show your cholesterol levels in milligrams per deciliter of blood (mg/dL). To determine how your cholesterol levels affect your risk of heart disease, your doctor will also take into account other risk factors such as age, family history, smoking and high blood pressure.

A complete fasting lipoprotein profile will show:

Your total blood (or serum) cholesterol level
Your HDL (good) cholesterol level
Your LDL (bad) cholesterol level
Your triglyceride level

Your Total Blood (or Serum) Cholesterol Level

Less than 200 mg/dL: Desirable
If your LDL, HDL and triglyceride levels are also at desirable levels and you have no other risk factors for heart disease, total blood cholesterol below 200 mg/dL puts you at relatively low risk of coronary heart disease. Even with a low risk, however, it’s still smart to eat a heart-healthy diet, get regular physical activity and avoid tobacco smoke. Have your cholesterol levels checked every five years or as your doctor recommends.

200–239 mg/dL: Borderline-High Risk
If your total cholesterol falls between 200 and 239 mg/dL, your doctor will evaluate your levels of LDL (bad) cholesterol, HDL (good) cholesterol and triglycerides. It's possible to have borderline-high total cholesterol numbers with normal levels of LDL (bad) cholesterol balanced by high HDL (good) cholesterol. Work with your doctor to create a prevention and treatment plan that's right for you. Make lifestyle changes, including eating a heart-healthy diet, getting regular physical activity and avoiding tobacco smoke. Depending on your LDL (bad) cholesterol levels and your other risk factors, you may also need medication. Ask your doctor how often you should have your cholesterol rechecked.

240 mg/dL and over: High Risk

People who have a total cholesterol level of 240 mg/dL or more typically have twice the risk of coronary heart disease as people whose cholesterol level is desirable (200 mg/dL). If your test didn’t show your LDL cholesterol, HDL cholesterol and triglycerides, your doctor should order a fasting profile. Work with your doctor to create a prevention and treatment plan that's right for you. Whether or not you need cholesterol-regulating medication, make lifestyle changes, including eating a heart-healthy diet, getting regular physical activity and avoiding tobacco smoke.

Your HDL (Good) Cholesterol Level


With HDL (good) cholesterol, higher levels are better. Low HDL cholesterol (less than 40 mg/dL for men, less than 50 mg/dL for women) puts you at higher risk for heart disease. In the average man, HDL cholesterol levels range from 40 to 50 mg/dL. In the average woman, they range from 50 to 60 mg/dL. An HDL cholesterol of 60 mg/dL or higher gives some protection against heart disease.

Smoking, being overweight and being sedentary can all result in lower HDL cholesterol. To raise your HDL level, avoid tobacco smoke, maintain a healthy weight and get at least 30–60 minutes of physical activity more days than not.

People with high blood triglycerides usually also have lower HDL cholesterol and a higher risk of heart attack and stroke. Progesterone, anabolic steroids and male sex hormones (testosterone) also lower HDL cholesterol levels. Female sex hormones raise HDL cholesterol levels.

Your LDL (Bad) Cholesterol Level

The lower your LDL cholesterol, the lower your risk of heart attack and stroke. In fact, it's a better gauge of risk than total blood cholesterol. In general, LDL levels fall into these categories:

LDL Cholesterol Levels

Less than 100 mg/dL
Optimal

100 to 129 mg/dL
Near Optimal/ Above Optimal

130 to 159 mg/dL
Borderline High

160 to 189 mg/dL
High

190 mg/dL and above
Very High

Your other risk factors for heart disease and stroke help determine what your LDL level should be, as well as the appropriate treatment for you. A healthy level for you may not be healthy for your friend or neighbor. Discuss your levels and your treatment options with your doctor to get the plan that works for you.

The Cholesterol Heart Profilers is a great starting point for learning about prevention and treatment options for your specific cholesterol levels. This free, confidential online service creates a printable report with the key information you need to fully understand your cholesterol levels, health risks and treatment options. You'll get a personalized cardiovascular disease risk profile, along with a summary of treatment options, potential side effects, success rates and a list of relevant medical journal articles and research studies, all summarized in plain English.

Your Triglyceride Level

Triglyceride is a form of fat. People with high triglycerides often have a high total cholesterol level, including high LDL (bad) cholesterol and low HDL (good) cholesterol levels.

Your triglyceride level will fall into one of these categories:
Normal: less than 150 mg/dL
Borderline-High: 150–199 mg/dL
High: 200–499 mg/dL
Very High: 500 mg/dL

Many people have high triglyceride levels due to being overweight/obese, physical inactivity, cigarette smoking, excess alcohol consumption and/or a diet very high in carbohydrates (60 percent of more of calories). High triglycerides are a lifestyle-related risk factor; however, underlying diseases or genetic disorders can be the cause.

The main therapy to reduce triglyceride levels is to change your lifestyle. This means control your weight, eat a heart-healthy diet, get regular physical activity, avoid tobacco smoke, limit alcohol to one drink per day for women or two drinks per day for men and limit beverages and foods with added sugars. Visit your healthcare provider to create an action plan that will incorporate all these lifestyle changes. Sometimes, medication is needed in addition to a healthy diet and lifestyle.

A triglyceride level of 150 mg/dL or higher is one of the risk factors of metabolic syndrome. Metabolic syndrome increases the risk for heart disease and other disorders, including diabetes.

Causes of high cholesterol level

There are several factors that may contribute to high blood cholesterol:
a diet that's high in saturated fat and, less so, high in cholesterol (see How diet affects cholesterol below)
lack of exercise may increase LDL ("bad") cholesterol and decrease HDL ("good") cholesterol
family history - people are at a higher risk of high cholesterol if they have a direct male relative aged under 55 or a female relative aged under 65 affected by heart disease
being overweight, which may increase LDL ("bad") cholesterol and decrease HDL ("good") cholesterol
age and sex - cholesterol generally rises slightly with increasing age, and men are more likely to be affected than women
drinking more than the recommended amount of alcohol (ie more than three to four units per day for men and two to three units per day for women)

Rarely, high cholesterol can be caused by a condition that runs in the family called a lipid disorder (familial hypercholesterolaemia). About one in 500 people have this condition.

Other health conditions such as poorly controlled diabetes, certain kidney and liver diseases and an underactive thyroid gland may also cause cholesterol levels to rise. Some medicines such as beta-blockers, steroids or thiazides (a type of diuretic) may also affect blood lipid levels.

How diet affects blood cholesterol

Only a small amount of cholesterol comes directly from your diet - the majority is produced by your liver. However, if your diet is high in saturated fats and cholesterol this can cause your liver to produce more LDL ("bad") cholesterol. The amount that diet influences cholesterol levels varies from person to person.

Measuring cholesterol

The amount of cholesterol in your blood is measured in units called millimoles per litre of blood, usually shortened to "mmol/litre" or "mmol/l". America uses the units milligrams per decilitre of blood: "mg/dl" instead. Current UK guidelines state that it is desirable to have a total cholesterol level under 5mmol/l, and an LDL level under 3mmol/l.

In order to estimate your risk of getting CVD, the best indicator of risk is your TC:HDL ratio. A lower ratio is desirable, because this indicates that you have high levels of HDL.

Measuring cholesterol involves a simple blood test. Usually you will be asked not to eat for 12 hours before the test so that your food is completely digested and doesn't affect the test. A blood sample may be taken either by using a needle and a syringe, or by using a finger prick. You can have this test at your GP surgery, at a hospital appointment, or as part of a health assessment examination.

Home-testing kits for cholesterol may not be very accurate. Also, cholesterol is just one of the risk factors for heart disease. It should ideally be measured under medical supervision so that other important issues, such as blood pressure, age and whether or not you smoke, are taken into account. Speak to your pharmacist about your result if you do choose a home testing kit.

Who should have a cholesterol test?

Anyone who has any cardiovascular disease, such as coronary heart disease, peripheral vascular disease (disease in the blood vessels that supply the limbs) or stroke, should have their cholesterol measured by a doctor.

Anyone, even children, with a family history of familial hypercholesterolaemia should have their cholesterol measured.

Anyone aged 35 or over should consider having their cholesterol measured if they have one or more of the following risk factors for CVD: family history of early heart disease, diabetes, high blood pressure, or if they smoke.

Diagnosis

Having a high cholesterol level does not cause symptoms. Most people find out they have high cholesterol when they have their blood cholesterol measured as part of a medical check-up. Alternatively, it may be identified after other health problems, such as heart disease, have been diagnosed.

Treatment

The main aim of lowering cholesterol is to reduce the risk of heart disease. The type of treatment depends on the overall risk of heart disease.

There are two ways to help lower high cholesterol. The first is with simple lifestyle changes including changing diet, managing weight and increasing exercise. The second is to combine lifestyle changes with cholesterol-lowering medicines.

Diet

Healthy eating can reduce cholesterol. Your diet should be low in saturated fats in particular, and low in fat overall. Biscuits, cakes, pastries, red meat, hard cheese, butter and foods containing coconut or palm oil all tend to be high in saturated fats, so cut down on these foods.

Large amounts of cholesterol are found in a few foods, including eggs, offal such as liver and kidneys, and prawns. However, if you're already eating a balanced diet, you don't need to cut down on these foods unless your GP or dietitian have advised you to.

It's also important to eat plenty of fibre, especially soluble fibre, which is thought to lower cholesterol. It's found in fruits and vegetables, beans and oats. Aim to eat at least five portions of fruit and vegetables each day. For more information see the BUPA factsheet, Healthy eating.

There is some evidence that foods containing substances called plant sterols or plant stanols, such as the brands Benecol or Flora pro.activ, in combination with a low fat diet and physical activity, can help to lower cholesterol.


Medicines

Cholesterol-lowering medicines are considered for people who already have CVD, or are at high risk of getting it because they have other risk factors.

The main group of medicines for lowering cholesterol are statins. Examples include simvastatin (Zocor) and atorvastatin (Lipitor). They work by reducing the production of cholesterol in the liver. Occasionally these drugs have side-effects such as indigestion and muscle pains. Other types of drugs to reduce cholesterol are called fibrates, nicotinic acids and cholesterol absorption inhibitors such as ezetimibe (Ezetrol) but these are generally less effective or have more side-effects. Your doctor will tell you more about these medicines.


Further information
The British Heart Foundation
08450 708 070
www.bhf.org.uk

Sources

Triglycerides and the heart. British Heart Foundation.
www.bhf.org.uk
accessed 12 October 2006
Heart disease. Food Standards Agency
www.eatwell.gov.uk
accessed 12 October 2006
Familial hypercholesterolaemia. HEART UK.
www.heartuk.org.uk
accessed 12 October 2006
Cholesterol. British Heart Foundation Health Statistics.
www.heartstats.org
Cholesterol and chronic kidney disease. National Kidney Foundation.
www.kidney.org
Law, M. Plant sterol and stanol margarines and health. British Medical Journal 2000: 861-864

chest pain an alarming symptom

Chest pain occur due to many reason.Among them unstable angina is very alarming.
unstable angina
What is unstable angina?

Stable angina, unstable angina and myocardial infarctions ultimately are all caused by the same process – coronary artery disease.

A myocardial infarction, or heart attack, occurs when a plaque ruptures in a coronary artery, leading to the sudden formation of a blood clot superimposed on the plaque. The blood clot often totally occludes the artery, leading to death of the heart muscle being supplied by that artery. And a myocardial infarction is the death of heart muscle.

Unstable angina occurs when a blood clot forms on a plaque, suddenly increasing the degree of blockage in a coronary artery. By definition, in unstable angina the clot does not completely occlude the artery, but merely increases the degree of blockage. Because blood flow across the blockage suddenly becomes more sluggish, angina occurs even at rest.

Indeed, the blood flow can become so sluggish, and the angina can persist for so long, that some of the heart muscle cells being supplied by the partially occluded artery can actually die in patients with unstable angina. Since the death of heart cells is the definition of a myocardial infarction, once some of the cells die, the patient has “officially” had a heart attack.
Our ability to detect cell death in patients with unstable angina has greatly improved over the past few years, mainly by the development of more sensitive assays for the enzyme, troponin. Troponin is a heart muscle protein that is released into the bloodstream when heart muscle cell death occurs. As our ability to measure troponin increases, more and more patients with unstable angina are being diagnosed with heart attacks.

This is what happened in Mr. Cheney’s case. His troponin level was found to be elevated a few hours after he was admitted, and this tipped off his doctors that his coronary artery blockage was severe enough to be causing cell death – albeit a very tiny amount of cell death.

How is unstable angina diagnosed?

Anybody with a history of coronary artery disease should suspect unstable angina if their angina occurs at a markedly lower-than-normal level of exercise, if it occurs at rest, if it persists longer than usual or is more difficult to relieve with nitroglycerin, or especially if it wakes them up at night. Any of these symptoms can indicate a suddenly “narrower” coronary artery, implying that a blood clot has superimposed itself on an atherosclerotic plaque.

People without any history of coronary artery disease can also develop unstable angina, but these individuals seem to be at higher risk because they often don’t recognize the symptoms.

The classic symptoms of angina include chest pressure or pain, sometimes squeezing or “heavy” in character, often radiating to the jaw or left arm.
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Unfortunately, many patients with angina do not have classic symptoms. Their discomfort may be very mild, and may be localized to the back, abdomen, shoulders, or either or both arms. Nausea or merely a feeling of heartburn may be the only symptom. What this means, essentially, is that anyone middle aged or older, especially anyone with one or more risk factors for coronary artery disease, should be alert to symptoms that might represent angina.

Not surprisingly, most people presenting with unstable angina have a history of known coronary artery disease. This is likely because they know what these symptoms mean, and they get themselves to the hospital before cardiac damage becomes irreversible. People without known coronary artery disease, on the other hand, tend to stay at home, explaining away their disturbing symptoms as something they ate or something they lifted – and they most often either die there, or finally come to the hospital once they’ve had a completed heart attack. Unstable angina is largely a condition of experience.

How is unstable angina diagnosed?

Unstable angina is usually diagnosed by the medical history and by the ECG. Patients complaining of symptoms consistent with angina, occurring at rest or with minimal exertion, especially when they have a history of coronary artery disease, should be presumed to have unstable angina.

Especially if the patient’s pain has been relatively prolonged, the doctor checks cardiac enzymes to determine whether heart muscle damage (i.e., a heart attack) has occurred. Until a few years ago, the chief cardiac enzyme that was measured was CPK. Rises in heart –muscle-specific CPK levels were unusual with unstable angina, so most of these patients were felt not to have muscle damage. However, in the past few years, since the enzyme troponin has been commonly measured, it has become apparent that a substantial proportion of patients presenting with typical unstable angina actually do have death of cardiac cells.

How should unstable angina be treated?

Until a few years ago, unstable angina was generally considered as basically an exacerbation of typical angina – that is, the pattern of angina changed for the worse, but because (it was thought) no heart cell damage occurred, the goal of therapy was simply to “quiet down” the angina with drugs, and send the patient home. If this could be accomplished, it was assumed, the patient was no worse off than before the angina became unstable.

However, it has now become clear that many patients presenting with unstable angina have a greatly increased risk, over the next few weeks to months, of having a full-blown heart attack, and even death. This, along with a better understanding of what causes unstable angina (that is, a blood clot forming at the site of an atherosclerotic plaque that slows but does not totally occlude blood flow) has led to the notion that much more aggressive management is needed.

Two general approaches to therapy have evolved: a) treat aggressively with drugs to stabilize the ischemia, then evaluate non-invasively (the Wait and See approach,) or b) treat aggressively with drugs to stabilize the ischemia, while at the same time planning for early invasive intervention (the Aggressive approach.)

What drugs are used to “stabilize” unstable angina?
Both the Wait and See and the Aggressive approaches involve the intensive use of medication to stabilize or eliminate the cardiac ischemia. These medications are generally aimed at either protecting the jeopardized heart muscle, or preventing further progression of the blood clot.

In the former category are beta blockers and intravenous nitroglycerin, both of which are started immediately. Beta blockers reduce the effect of adrenalin on the heart muscle, and nitroglycerin reduces the cardiac workload by lowering cardiac muscle tension. Both of these effects reduce the amount of blood flow needed by the cardiac muscle. In “clot stabilizing” category are either heparin or enoxaparin (drugs that inhibit the thrombin clotting system) and aspirin and/or IIb/IIIa inhibitors (drugs that inhibit platelets).
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What is the Wait and See approach?

Using this approach, patients are carefully observed in the coronary care unit for signs of continuing ischemia. Such signs include more chest discomfort, further changes in the ECG, or continuing rises in cardiac enzymes.

If there are no further signs of ischemia, then patients are converted to an all-oral drug regimen they can continue at home. Before discharge from the hospital, a stress and thallium study is done to assess the patient’s potential for developing further ischemia. If the stress test is favorable, they are discharged to home. If, on the other hand, signs of early ischemia are seen on the treadmill test, they are sent for catheterization and angiography, in order to be evaluated for possible revascularization (angioplasty and/or stent, or bypass surgery.)

Using the Wait and See approach, approximately half the patients are discharged from the hospital without receiving catheterization.
What is the aggressive approach?
The aggressive approach begins the same way as the Wait and See approach, that is, with intensive drug therapy to stabilize the ischemia. But while this is being done, arrangements are being made to perform catheterization and angiography, with the clear goal in mind of doing angioplasty and/or stent. This procedure is performed as soon as it can be done practically.
Which approach is better?
This has been a very controversial question. Many patients do very well with the more conservative Wait and See approach to unstable angina.

But as noted, when Mr. Cheney was admitted to the hospital there was little hesitation in going quickly to an aggressive treatment regimen, and most medical commentators agreed that this was indeed the correct approach in his case.

What can we say about the appropriateness of the conservative approach vs. the aggressive approach?
Thanks to data accumulated over the past year or two, we can say the following regarding therapy given to patients with unstable angina:
In patients with ECG changes and elevated troponin levels early interventional therapy yields a significantly reduced incidence of full-blown myocardial infarction, and of death. In these patients, the Aggressive approach should now be considered as standard.
In patients with no ECG changes and with normal troponin levels, there is no evidence to date that aggressive early catheterization yields better results. In these patients, the Wait and See approach is entirely appropriate.

Summary

We now know that in most patients, unstable angina represents an acute deterioration in a previously stable atherosclerotic plaque. Indeed, the essential difference between unstable angina and a classic myocardial infarction is simply that in unstable angina, the acute blood clot only partially occludes the coronary artery instead of completely occluding it. For this reason, and because patients who are “stabilized” using medical therapy are now known to have a high incidence of having a classic heart attack in the near future, unstable angina probably is best thought of as being an “incomplete myocardial infarction.” This fact justifies an aggressive early approach in many patients with unstable angina.

At this point in time, many doctors in many emergency rooms have not yet gotten “up to speed” in the appropriate treatment of unstable angina. They still think of unstable angina in terms of being somewhat-worse-than-usual angina, instead of being a somewhat-milder-than-usual heart attack. This is a problem. Even the Wait and See approach to unstable angina is far more aggressive than the treatment used for routine angina. Patients whose doctors who do not treat unstable angina with sufficient respect are at extremely high risk for a poor outcome.

Mr. Cheney was fortunate to have up-to-date doctors. But in the end he did not receive exotic or unusually aggressive treatment. He just received excellent, but standard, medical care. There’s no reason we shouldn’t all expect exactly the same treatment.

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