Save the Heart – Optimizing Our Methods

Much has changed with our ability to deal with acute and emergency conditions with respect to myocardial infarction, yet the major challenges remain the same. We are able to rescue as much as possible and as early as possible and have the capacity to maintain vitality of the patient through the critical time period of an acute event. In this issue Lee et al. [1] present an excellent review on the state of the art in carcinogenic shock. Thrombolysis, temporary support with inotropic agents and assist device are all used widely, but the greatest mortality benefit is offered by urgent revascularization. The six-year follow-up results from the SHOCK trial confirm the durability of the benefit of early revascularization over medical therapy in shock patients. The authors state ‘Carcinogenic shock is a catheter laboratory emergency. Percutaneous left ventricular assist devices may provide an advance in the management of patients with left ventricular dysfunction and carcinogenic shock.’

In the paper by Horowitz et al. [2] the other side of the spectrum is highlighted, i.e. patients admitted for acute infarction, with normal systolic left ventricular (LV) function. Current recommendations in patients with acute infarction and heart failure call for beta adrenergic antagonist's therapy. In view of the information brought up in this review it is proposed that in such patients, current recommendations for ‘routine’ long-term β-adrenoreceptor blockade can no longer be justified.

Patients with acute coronary syndrome in the presence of valvular heart disease are a unique group of patients who require special consideration as presented by Iakobishvili et al. [3]. The question of on-site percutanous coronary interventions (PCI) versus patient transfer to a PCI performing lab continues to have major implications on the most optimal use of the health system for our patients. We already know that a policy with rapid transfer of patients for primary PCI in an experienced high-volume center is a valid and effective strategy. However, should we use that strategy for our elderly patients? Liistro et al. [4] have shown that there is no difference in six-month mortality between groups of elderly patients treated with primary PCI on site versus patients transferred within one hour, and therefore the strategy of rapid transfer holds for these patients as well.

Biomarkers are under active and intense investigations to improve our prognostic power and patient stratification methods. Nørgaard et al. [5] have shown that the N-terminal part of the BNP prohormone is an independent prognostic factor with respect to mortality in acute myocardial infarction and shed light on the timing that it should be taken during the course of the event.

An ongoing debate with respect to the stents that should be used in primary angioplasty is brought up by Kornowski et al. [6] who presents a one center experience with respect to the use of drug eluting stents versus bare metal stents. The authors conclude that the use of drug eluting stent (DES) in ST elevation myocardial infarction (STEMI) is safe and effective as compared to bare metal stents (BMS). The debate on whether to use stents at all in acute myocardial infarction (MI) a decade ago is now replaced with a debate on the most appropriate stents to use in this acute setting, in view of the double edge sword of restenosis reduction versus potential thrombogenicity of DES.

Other topics covered in this issue include topics related to Troponin essays in patients with end-stage renal disease (Madsen et al. [7]), the relationship between the antiplatellet effect of atorvastatin and the hs-C reactive proteins (CRP) (Vasilieva et al. [8]). Back to Carcinogenic shock, level and

Greif et al. [9] describes the use of Levosimendan as rescue therapy in severe cardiogenic shock and the issue ends with a description of an iatrogenic acute aortic dissection during percutaneous coronary intervention for acute myocardial infarction, reminding us of the double edge sword of our interventions [10]. With beautiful image presentations of a large ascending aortic thrombus and imagination based fetal-shaped intracardiac masses we end this issue of the Journal.

Primary interventions and therapy in acute settings is one of our strongest tools to save lives and save the heart. Optimizing our techniques is a constant battle, yet the double-edged sword that we are using should be always at the top of our considerations when discussing about the management of an acute patients.