Myocardial infarction-fighting no reflow and creating systems of intervention to improve long term survival

Treatment of Acute Myocardial infarction continues to be at the center of acute cardiac care. A regional system of care for ST elevation myocardial infarction and its effect on long term mortality is presented by Saia et al. (1). In this study, the organizational phases for better treatment of STEMI were associated with increased rates of reperfusion and reduction of long-term mortality.

One of the major predictors of long term mortality in myocardial infarction patients presenting in cardiogenic shock is the development of Mitral regurgitation (2). Cardiogenic shock in association with mitral regurgitation is a superposition of severe myocardial insult and a valvular problem that adds to the severity of the consult. Mitral regurgitation has long term consequences of increased load on the already jeopardized ventricle and as shown here impedes prognosis at 1 year. A very interesting paper by Movahed et al. (3) describes the nationwide trends in the age adjusted prevalence of non- ST elevation myocardial infarction across various races and gender in the United State. This heterogeneity can be explained by genetic, cultural and habitual variations between societies, and can provide a strong basis for national planning of prevention and intervention programs. Genetic variability between populations can be now tested with very fast multi-gene arrays. In the near future bio-informatics will be a strong part of any population based analysis.

No reflow has been and continues to be a challenge to acute coronary interventions. Methods to prevent and reduce the consequences of no reflow have ranged between catheter based aspiration, distal filtering systems and pharmacological agents through a variety of mechanisms. Lee et al. (4) describes the relationship between no-reflow and six-month mortality in elderly Asian patients undergoing primary percutaneous coronary intervention. The association between mortality and no-reflow is guiding us to seek for methods to prevent no-reflow which will probably translate into long term mortality improvement.

Ando et al. (5) have described transient left ventricular dysfunction in patients with neurogenic cardiomyopathies, a field with growing interest due to the multidisciplinary implications.

The issue is closed by a letter on Bivalirudin use during percutaneous coronary interventions in patients with ST segment elevation myocardial infarction (6) and with an image of Three-vessel coronary artery disease with multi-vessel proximal aneurysms (7).

We look forward towards improved outcomes with respect to acute interventions that are associated with no reflow. The solutions are not there yet and the search continues.