From shock, inflammation and good-old-electrocardiography towards the need of new guidelines for left main stenting

This issue is focused on acute cardiac presentations and shares some new and interesting thoughts and hypotheses. The first review paper by Shpektor et al (1) deals with the role of inflammation in cardiogenic shock patients, a condition that primarily originates from mechanical reasons of pump failure. The high mortality rate in these patients has not changed dramatically, despite all modern therapeutic tools including pharmacological therapies, the use of novel cardiac assist devices and urgent revascularization techniques that are attempted in some acute cases. Inflammation as a major role in this condition is well presented and discussed in this review paper.

Bar-Yishay et al (2) are discussing unique electrocardiographic presentation criteria for acute myocardial infarction (AMI). While we are all so knowledgeable today about the precise anatomy of the infarct related artery and what needs to be done to open the artery, we often fail to recognize the electrocardiographic patterns that help in localization and correct diagnosis of AMI in certain cases. The Electrocardiography (ECG) that is with us since the beginning of last century is still the number one diagnostic tool in acute cardiac conditions until the patient crosses the door of the interventional suit and continued to be critical in the routine follow-up and management of these patients. An old and good wine, if properly handled improves its taste. It is amazing how the Einthoven innovation of the ECG in the beginning of the last century continues to impact our daily life. The authors have shown here that isolated ST depression in the inferior leads can present the early signs of anterior MI before any ST elevation develops. Obviously, such patients can lose the opportunity for the most appropriate therapy if not properly diagnosed. Every one of us has to know how to master this technique and refinements of ECG diagnosis are still described as shown by this interesting paper.

The very hot topic of unprotected left main stenting is presented by Qarawani et al (3). In the single center experience in 238 patients, procedural success rate was 100%, in hospital mortality 2.1% and the additional mortality during a 3 year follow up was 5%. These are excellent clinical results. This paper presents additional data on the differential use of BMS and DES and shows again that left main stenting is a valid option in the acute and subacute setting as well as in the chronic setting of ischemia. The authors conclude that drug-eluting stent implantation for unprotected left main coronary artery stenosis appears safe with regard to acute and long term complications and is more effective in preventing restenosis compared to BMS implantation. Re-consideration of the accepted guidelines that advocates for surgical approach in these patients is recommended. These real life single center data are certainly comparable to surgical data. We know from the Syntax study that clinical outcome in left main cases depends at large on the anatomical complexity of the lesion and the extent of additional disease. Yet, this study shows us that with proper selection of cases and a balanced decision between surgical and interventional approaches, excellent clinical results can be obtained in both modalities.

Finally, the diagnosis of acute myocardial infarction with the new universal definition was weighted against the prediction of the risk stratification and guidance for interventions (4). It is shown that while the new universal definition significantly increased the diagnosis of AMI in patients with non ST elevation acute coronary syndrome, it was not an independent predictor of prognosis. The GRACE Risk Score was the only independent predictor of prognosis. This is an important finding that emphasized the recommendation for its use as advocated by current guidelines. Higher risk patients defined by the GRACE Risk Score benefited more from myocardial revascularization.

Overall, this condensed issue sheds a new balanced light on the field of acute cardiac care and the guidelines and modes of revascularization and intervention. It challenges the field with new thoughts and important data that should be considered in each acute care setting.