Time, Time, Time, see what's become of me; While I looked around for my possibilities; I was so hard to please. (From Simon and Garfunkel's Hazy Shade of Winter)

Acute Myocardial Infarct (AMI) due to acute thrombotic coronary occlusion is a synonym for a rapidly progressive necrosis of myocardium, with increasing damage to overall cardiac pump function. While nature have provided us with mechanisms to negotiate this emergency threat to life by activation of the fibrinolitic pathways to dissolve the clot, advances in medicine allow us to negotiate this emergent demand supply mismatch and facilitate reperfusion. In general, the 3 primary methods of revascularization are pharmacologic, transcatheter interventions and surgical. The third one has been abandoned long ago due to high rate of mortality of patient undergoing surgery under this acute condition. The pharmacological methods and the primary PCI methods remain and are used interchangeably according to the ability of the institution and the suitability of the patients. It is clear that what we want to achieve is the fastest and safest way for myocardial reperfusion within the limited short time window available to us. It is under our jurisdiction to provide adequate timely access to an interventional facility to all patients suffering from AMI.

In the review by Taglieri and Di Mario [1], the current literature on the optimal way to synergistically use the two primary reperfusion techniques is discussed. The synergy between PCI and thrombolysis has been supported by modern randomized control trials and meta-analysis of available randomized trials. It is important that operational model of territorial network for the treatment of AMI patients should be expanded to provide a timely access to hospital with interventional facilities also to patients treated with fibrinolysis that need rescue-PCI or an urgent/early invasive management.

Another emergent situation in medicine is acute heart failure (AHF). The time scale here can also be very short if immediate support is required, or longer if acute on chronic heart failure develops and mandates interim assistance to the failing heart. In a review article by Pitsis and Visouli [2], the various aspects of current and prospective mechanical circulatory support for this indication is discussed. We know that the mortality of AHF remains high despite advances in treatment. The support strategies and the indications for the use of mechanical circulatory support (MCS) systems are continuously evolving, appropriate patient selection, advanced device technology and improved patient management have contributed to the substantially improved results. Earlier stage application of MCS, with novel, flexible and individualized support strategies is now feasible. Bridging to recovery is the most intriguing support strategy and bridging to future treatments is feasible with long term support. The progressively expanding role of MCS in the treatment of heart failure is not reflected in the existing guidelines. In this article you will find your selected strategy for treating the patient thriving for life due to acute circulatory failure.

Coronary perforation is a dreadful acute event in the cathlab where the time scale for interventions is seconds to minutes. Although it is a rare event, the development of tamponade happens within minutes and the response should be prompt and efficient in both, sealing the leakage and detaining the pericardial effusion, thus preventing tamponade. A single center experience in 2991 patients [3] reports 0.1% occurrence of this complication for non- debulking technologies.

At a longer time scale are the strategies for prevention of further disease in patients discharged after acute myocardial infarction. It is interesting that the long term therapy of these patients depends on the initial short term strategy of reperfusion. The results from the IN-ACS Outcome Study in 6045 acute coronary syndrome (ACS) patients admitted within 48 hours to the hospital is presented below by Pedone et al. [4]. There is a clear discrepancy of long term treatment where the non-reperfusion patients, despite the higher risk profile, were less frequently receiving antiplatellet beta-blockers and statins at discharge.

And back to the future. Heart sounds is an old technology, initially kept by the fine auditory training of the expert cardiologist ear, and lately subjected to computerization and quantitative analysis. The association of diastolic heart sound and ischemia, part of our medical school textbook, is back on stage. Please read the paper by Lee et al. [5] in this issue of the Journal.

Stratification of prognosis based on serum biomarkers for ACS is discussed by Timóteo et al. [6] who reported the short-term prognostic impact of admission NT-proBNP in patients admitted for ACS. Biomarkers are also guiding us as to the timescale of the approach to the acute patient as discussed below.

Another very interesting issue with respect to the subacute management of patients after successful revascularization for AMI presented by Viana-Tejedora et al. [7]. It is clear to all of us dealing with the acute setting that a patient with AMI after successful and uneventful angioplasty at a short time window, requires less intensive care as compared to a patient with unsuccessful revascularization. What is the appropriate length of hospital stay in the coronary care unit (CCU) for patients with ST elevation AMI. Viana-Tejedora et al. [7] have shown among patients with successful primary PCI that none of the patients had any adverse event that could not be resolved in a step-down unit with a very high short and intermediate survival rates. While the median of CCU stay was 3 days for these patients, would a shorter one be associated with similar outcome? Certainly, savings on CCU and hospital time can be substantial. Furthermore, should we discharge home a patient after primary PCI with very little myocardial damage at much shorter time window than customary today? If we are sure that the balanced risk of vessel thrombosis are eliminated by safer drugs and the patient is better off at home with an excellent rehabilitation and life style modification program- why not?

In a letter to the editor Kaneda et al. [8] describes a patient treated for chronic total occlusion of the LAD for stable angina pectoris with a challenge of repeated plaque prolapse, certainly a procedure where the time frame is long. In another letter by Zacà et al. [9] it is described how a young bodybuilder abusing nandrolone and erythropoietin develops ventricular septal defect and carcinogenic shock following acute myocardial infarction and eventually undergoes heart transplantation [9]. Finally an interesting rare image of intramural left atrial hematoma following a coronary perforation during PCI in a patient with inferior myocardial infarction is presented.

Once we have the right tools, timely management of patients is one of the key factors in patient management. From seconds and minutes for management of perforations, minutes to a few hours for managing AMI and AHF and optimizing timely management of patients under less intensive settings.