Résumés
Résumé
On distingue maintenant les syndromes coronariens aigus avec ou sans élévation (ou sus-décalage) du segment ST. Les premiers correspondent à une occlusion complète durable d’une artère coronaire et nécessitent un traitement de désobstruction en urgence, par thrombolyse intraveineuse ou par angioplastie. Dans les syndromes coronariens aigus sans élévation du segment ST, la stratification du risque est un élément fondamental de la prise en charge, permettant de distinguer les formes nécessitant une exploration coronarographique précoce et celles dont le diagnostic reposera sur des examens non invasifs. Parmi les facteurs de mauvais pronostic, il faut retenir essentiellement la répétition des douleurs de repos, l’existence de modifications du segment ST sur l’électrocardiogramme et l’augmentation des marqueurs biologiques de nécrose myocardique. Dans tous les types de syndromes coronariens aigus, un traitement de prévention secondaire est impératif pour tenter de freiner l’évolution de la maladie athéroscléreuse.
Summary
There are two types of acute coronary syndromes : those with or without ST-segment elevation. The former require urgent therapeutic measures to reopen the culprit artery (intravenous thrombolysis or primary percutaneous coronary intervention). For the latter, risk stratification is essential and is based upon clinical and biochemical markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponin levels) are strong predictors of untoward outcome. According to the risk profile, the initial management is based upon an invasive strategy with powerful antithrombotic medications and urgent angiography, or upon a non-invasive strategy using stress testing, preferably coupled with myocardial imaging techniques. In all instances, secondary prevention measures are determinant to try and stop the progression of the atherosclerotic disease.
Parties annexes
Références
- 1. A consensus document of the Joint European society of cardiology/American college of cardiology committee for the redefinition of myocardial infarction. Eur Heart J 2000 ; 21 : 1502-13.
- 2. ISIS 2 (second international study of infarct survival) collaborative group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of suspected acute myocardial infarction : ISIS 2. Lancet 1988 ; 2 : 349-60.
- 3. The GUSTO investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993 ; 329 : 673-82.
- 4. The GUSTO IIb angioplasty substudy investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997 ; 336 : 1621-8.
- 5. Bonnefoy E, Lapostolle F, Leizorovicz A, et al. On behalf of the CAPTIM study group. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction : a randomised study. Lancet 2002 ; 360 : 825-9.
- 6. Every NR, Parisons LS, Hlatky M, et al. For the myocardial infarction triage and intervention investigators. A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. N Engl J Med 1996 ; 335 : 1253-60.
- 7. Danchin N, Vaur L, Genès N, et al. Treatment of acute myocardial infarction by primary coronary angioplasty or intravenous thrombolysis in the « real world » : one-year results from a nation-wide French survey. Circulation 1999 ; 99 : 2639-44.
- 8. Freemantle N, Cleland J, Young P, et al. Beta-blockade after myocardial infarction : systematic review and metaregression analysis. Br Med J 1999 ; 318 : 1730-7.
- 9. ISIS-4 (fourth international study of infarct survival) collaborative group. ISIS-4 : a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. Lancet 1995 ; 345 : 669-85.
- 10. Gruppo Italiano per lo studio della sopravvivenza nell’infarto miocardico. GISSI-3 : effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Lancet 1994 ; 343 : 1115-22.
- 11. Braunwald E. Unstable angina. A classification. Circulation 1989 ; 80 : 410-4.
- 12. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without ST segment elevation : Results from an international trial of 9,461 patients. Circulation 2000 ; 101 : 2557-67.
- 13. White HD, Wong CK. Risk stratification and treatment benefits in patients with non-ST-elevation acute myocardial infarction. Eur Heart J 2002 ; 23 : 187-91.
- 14. Antman EM, Cohen M, Bernink PJLM, et al. The TIMI risk score for unstable angina/non ST elevation MI. A method for prognostication and therapeutic decision making. JAMA 2000 ; 284 : 835-42.
- 15. Kaul P, Fu Y, Chang WC, et al. Prognostic value of ST segment depression in acute coronary syndromes : insights from PARAGON-A applied to GUSTO-IIb. J Am Coll Cardiol 2001 ; 38 : 64-71.
- 16. Jernberg T, Lindahl B, Wallentin L. The combination of a continuous 12-lead ECG and troponin T. A valuable tool for risk stratification during the first 6 hours in patients with chest pain and a non-diagnostic ECG. Eur Heart J 2000 ; 21 : 1464-72.
- 17. Heindrich PA, Alloggiamento T, Melsop K, et al. The prognostic value of troponin in patients with non-ST elevation acute coronary syndromes : a meta-analysis. J Am Coll Cardiol 2001 ; 38 : 478-85.
- 18. De Lemos JA, Morrow DA, Bentley JH, et al. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes. N Engl J Med 2001 ; 345 : 1014-21.
- 19. Morrow DA, Antman EM, Snapinn SM, et al. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes : application of the TIMI risk score for UA/NSTEMI in PRISM-plus. Eur Heart J 2002 ; 23 : 223-9.
- 20. Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999 ; 281 : 707-13.
- 21. Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes : a meta-analysis of all major randomised clinical trials. Lancet 2002 ; 359 : 189-98.
- 22. The clopidogrel in unstable angina to prevent recurrent events trial investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001 ; 345 : 494-502.
- 23. Fragmin and fast revascularisation during instability in coronary artery disease investigators. Invasive compared with non-invasive treatment in unstable coronary-artery disease : FRISC II prospective randomised multicentre study. Lancet 1999 ; 354 : 708-15.
- 24. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001 ;344 : 1879-87.
- 25. Fox KAA, Poole-Wilson PA, Henderson RA, et al. For the RITA investigators. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction : the British heart foundation RITA 3 randomised trial. Lancet 2002 ; 360 : 743-51.
- 26. Bertrand ME, Simoons ML, Fox KAA, et al. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. The Task force on the management of acute coronary syndromes of the European society of cardiology. Eur Heart J 2002 ; 23 : 1809-40.
- 27. Antithrombotic trialists’ collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. Br Med J 2002 ; 324 : 71-86.
- 28. The Scandinavian simvastatin survival study group. Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease : the Scandinavian simvastatin survival study (4S). Lancet 1994 ; 344 : 1383-9.
- 29. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and recurrent events trial investigators. N Engl J Med 1996 ; 335 : 1001-9.
- 30. Heart protection study collaborative group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals : a randomised placebo-controlled trial. Lancet 2002 ; 360 : 7-22.
- 31. The heart outcomes prevention evaluation study investigators. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000 ; 342 : 145-53.
- 32. The Europa trial : design, baseline demography and status of the substudies. Cardiovasc Drugs Ther 2001 ; 15 : 169-79.
- 33. Pitt B, Waters D, Brown WV, et al. For the atorvastatin versus revascularization treatment investigators. Aggressive lipid lowering therapy compared with angioplasty in stable coronary artery disease. N Engl J Med 1999 ; 341 : 70-6.
- 34. Steinhubl SR, Berger PB, Mann JT, et al. For the CREDO investigators. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention. A randomized controlled trial. JAMA 2002 ; 288 : 2411-20.