Coronary angioplasty in patients with unstable angina pectoris: Is there a role for thrombolysis?

Management of unstable angina has evolved progressively, and coronary angioplasty has recently been shown to be an effective treatment strategy for unstable angina. However, the procedure-related major complication rate is higher when compared with that for angioplasty in stable angina. The underlying palhophysiology may explain this higher complication rate. Rupture of an atherosclerotic plaque associated with thrombus formation is frequent in the pathogenesis of unstable angina. These processes lead to a critical reduction in myocardial plod supply, aad coronary angioplasty may effectively interrupt this process. In contrast, coronary angioplasty itself may cause further injury of the already ulcerated intima, have the potential to intensify the ongoing thrombogenic process and lead to an increased frequency of abrupt closure of the artery during the procedure. Therefore, intracoronary streptokinase was used in the procedure in those patients with abrupt closure of the artery immediately after dilation to attempt to improve the immediate result. Coronary angioplasty was attempted in 200 consecutive patients with unstable angina. Initial success in crossing the obstructed artery was achieved in 196 patients; however, an abrupt closure immediately after dilation occurred in 21 of these patients. Of these 21 patients, 12 were also treated with intracoronnry streptokinase, and successful dilation was achieved in 9 patients without evidence of necrosis or the need for emergency bypass surgery. Of the remaining nine patients, four successfully underwent redilation with a larger-sized balloon, four underwent urgent surgery (one death postoperatively) and one was treated conventionally. Final success was achieved ia 188 patients (94%) without death, the need for emergency surgery or evidence of myocardial necrosis. These beneficial results suggest that, in some cases, coronary angioplasty may need to be supplemented by additional intracoronary thrombolysis to improve immediate outcome by avoiding urgent surgery and procedure-related myocardial infarction.