Unstable Angina of Crescendo Pattern vs New Onset: A Clinical,Coronary Arteriographic and Hemodynamic Study

Abstract

Unstable angina includes a variety of clinical presentations with a different level of risk for an unfavorable outcome. In this study the authors investigated the prognostic signif icance of crescendo angina and new-onset angina to discuss management strategies, paying attention to the relevance of baseline clinical characteristics, coronary artery lesions, and left ventricular function, as well as their alterations during atrial pacing. Accordingly coronary arteriographic anatomy and changes in left ventricular volumes and ejection fraction before and during atrial pacing were studied by means of digital subtraction ventriculography in 18 patients with crescendo angina and in 18 patients with new-onset angina. Triple-vessel disease was more frequently observed in crescendo angina (56%; P < 0.05) as compared with the patients with new-onset angina (11%). Complex coronary morphology was statistically more likely to be found in crescendo angina. The angiographic evidence of intracoronary thrombi was found in 33% (P < 0.05) patients with crescendo angina and in 4% patients with new-onset angina. Compared with the patients with new-onset angina, patients with crescendo angina had higher end-diastolic and end-systolic volumes and lower ejection fraction at rest. At peak pacing, ejection fraction was significantly (P < 0.05) lower in crescendo angina (0.48 ±0.06) than in new-onset angina (0.66 ±0.04). In crescendo angina, during pacing, the magnitude of velocity of circumferential fiber shortening was significantly decreased as compared with new-onset angina.

Thus, our findings document more extensive coronary atherosclerosis and more severe left ventricular dysfunction in patients with crescendo angina than in patients with new-onset angina, which may explain the poorer outcome in the former subgroup of patients.