Biomarkers, imaging and interventions – going up hill

Acute Cardiac Care continues to challenge us by its interdisciplinary nature in combining the best tools available for medical care. In this issue of the Journal, we avoid the drug eluting stent controversy that floods the cardiology literature these days, but we are fascinated by our ever‐growing ability to affect the management and outcome of our acutely ill patients, and we enjoy the wide range of this fascinating field at its best.

Konstantino et al [1] review the available non‐traditional biomarkers that differentiate between stable and unstable coronary artery disease. We all need a simple blood test to tell us if a certain patient is likely to have an unstable coronary syndrome. This can change the reality in the Emergency Room and guide our approach to patients in the CCU or in the Internal Medicine ward. Risk stratification is another key component in the stratification of medical care and in optimizing medical therapy.

Heart failure, another devastating disease, an epidemic in terms of its widespread appearance in the western world, also seeks fine tuning in prognosis and management, as well as stratification and guidance of management using biomarkers. Edwards et al [2] provide us with a comprehensive review of the value of biomarkers for prognostic implications in heart failure. Stratification of risk can be employed effectively in patients with heart failure, as well as a guide for therapy.

Paradoxically, we will continue to see a growing numbers of heart failure patients with improved management of heart disease in the coming years. This will result from prolongation of life and from our ability to delay the onset of disease to older ages. Myocardial loss is present in almost every acute coronary event and is cumulative over the prolonged life span of our patient today. Our ability to treat those patients effectively will depend on biomarkers, among other therapeutic options. A case description followed by an extensive review of the literature results in a fascinating chapter to the reader here [2].

Our diagnostic and prognostic abilities depend at large on imaging, i.e., providing physicians with anatomical markers of disease. These “imaging markers” are ever improving, while also costing the patient a certain price. Additional knowledge always comes at a cost. The charge is both economical (paying for the imaging examination by the patient, via health insurance or by the tax payer) and clinical (using a contrast agent with its potential for renal toxicity and exposure to excess radiation). The debate on how and when to use imaging is highlighted in the setup of patients seeking medical care for acute chest pain. Schuijf et al [3] have provided us with an up‐to‐date review of this subject. This is a very common problem in our daily life, with a considerable number of patients presenting to the Emergency Department with acute chest pain complaints. The purpose of this review, which was presented in last year's “Acute Cardiac Care” meeting in Prague, is to discuss the potential roles of calcium scoring and non‐invasive coronary angiography in patients presenting with suspected ACS. The availability of sophisticated imaging techniques, side‐by‐side with biomarkers, will continue to modify our clinical assessment paradigm.

And from here to therapeutics, to our very powerful tools with the potential to modify the disease processes. Most of us have had personal experience with a patient who was crashing with cardiogenic shock and needed hemodynamic support. We have all experienced the frustrating condition where, despite all the support we could provide, the patient deteriorated quickly and succumbed because of acute pump failure. The need for a quick and effective assist has always been pushing us in these intense moments of struggle for the patient's life. An excellent review on the “state‐of‐the‐heart” of percutaneous cardiac assist for the treatment of myocardial infarction is given by Sjauw et al [4]. The world of percutaneous ventricular assist has left its stagnant phase and is rapidly changing. The current advantages, limitations and future perspectives of each of the novel methods for assisting the heart are reviewed.

The physiology of coronary flow using a total frame count during angiography is the subject of investigation in the paper by Vijayalakshmi et al [5]. Methods to assess coronary flow and its dependence on catheter size is nicely presented and discussed in this paper.

Our therapeutic measures are sometimes good for a relative short time but, in many cases, have an established life‐long durability. This is shown in the first patient treated with thrombolysis in the Czech Republic. The very long‐term effect of thrombolytics for acute MI is presented in this Journal by Widimsky et al [6]. Twenty‐four years after the first successful intracoronary thrombolysis for ST elevation myocardial infarction, the patient is entirely asymptomatic. Thrombolysis that shifted from intracoronary application to systemic intravenous management is now shifting back to the intracoronary domain, with the increasing use of percutaneous interventions for acute MI.

Another emerging method to combat myocardial loss and restore ventricular function is the use of stem cells. Intramyocardial bone marrow transplantation is a clinical “quick and dirty” approach that is still controversial with respect to its effectiveness and safety. Other approaches are also under intense investigation in preclinical models and clinical pilot studies. The risks with these approaches include, among others, the progression of atherosclerosis. Beeres et al [7] present their data from two trials on this problem in patients with chronic myocardial ischemia. They conclude that intramyocardial bone marrow cell transplantation in patients with chronic myocardial ischemia is not associated with significant progression of atherosclerosis. Read this original article for more information.

Two fascinating images paint this issue of the Journal with practical advice. A left‐sided superior vena cava that occurs in 0.3% of the population presents a pacing challenge to the physician who needs to get the lead into the heart [8]. Extensive coronary thrombus causing a transmutable myocardial infarction in a young patient is illustrated [9]. Compare this image to the result of the 24‐year old first thrombolysis in the Czech Republic [6].

This issue ends with an interesting letter to the Editor, describing a combined percutaneous coronary intervention and atrial septal defect closure in an adult patient [10].

This Journal is an integrated combination of prognostic, diagnostic and therapeutic interventions for the acute cardiac patient. It leaves the reader with thoughts and guidance for his daily practice and provides him the challenge of further exploration of disease and its management.