In this first issue of 2013, three manuscripts present technologies and strategies to improve the outcomes of patients experiencing acute myocardial infarction (MI) . These manuscripts represent a small sampling of the extensive research and ongoing work in the quest to improve the cardiovascular care for this acute patient population. Despite the tremendous advances and radical changes in cardiovascular medicine regarding the management patients with STEMI, including thrombolytic therapy and primary percutaneous coronary intervention (PCI), MI remains one of the leading causes of death and disability in the United States. According to the American Heart Association 2010 Statistical Update, in 2006 there were approximately 935,000 cases of MI in the United States, approximately 8.5 million people who had previously suffered an MI, and 17.6 million with heart disease. In addition, more than 425,400 deaths occurred from various forms of coronary heart disease, and 141,500 deaths directly due to MI. Acute interventions and continued efforts to shorten the time from symptom onset to an open artery have resulted in a nearly 40% decline in mortality. As a result, we have seen a reduction in complications post-ST elevation myocardial infarction (STEMI) heart failure, which has had a profound impact on the morbidity and mortality 5 years’ post acute MI.

The first breakthrough in the treatment of patients with STEMI was in the early 80’s when streptokinase was administered intracoronarily and resulted in a threefold reduction of 30-day mortality . This later evolved into peripheral administration of thrombolytic therapy, starting with the initiation of home thrombolysis programs and the switch to more efficacious thrombolytic agents, such as tissue plasminogen activator. The second breakthrough in the treatment of these patients occurred in the mid 90’s with the introduction of primary PCI, which today remains the standard of care if feasible . The next campaign, endorsed by all of the cardiovascular societies, aimed to shorten the door-to-balloon time to under 90 min. While outstanding efforts and resource allocations have helped to accomplish this goal for the majority of institutions with an active primary PCI program, we are still awaiting definitive proof that these efforts are associated with further reduction in mortality and infarct size. Over the last decade numerous research efforts have aimed to reduce myocardial injury using a variety of agents, such as hyperbaric oxygen, cooling of the heart, thrombectomy and aspiration devices, mechanical assist devices, and infusion of antiplatelet agents. In large, these efforts have produced mixed results, but collectively have not resulted in reduced mortality rates or infarct size. Among the explanations to these disappointing outcomes are: i) the heterogeneity of the patients presenting to the hospital with STEMI; ii) large span of symptom-to-door times; and iii) a variety of vessel locations for the infracting lesions. The question remains whether we have reached a plateau in our ability to further reduce the mortality rate of the STEMI population and what should be done to achieve a further reduction in cardiovascular mortality? Will the breakthrough come by aggressive use of mechanical support such as LVAD, or artificial heart, or cell therapy with regeneration of myocardium, or a simpler, more cost effective solution?

While we search for this magic bullet, whether it be a device or drug, we should focus more on patient education. We must shift our efforts toward informing patients of the signs and symptoms of MI and to educating them on how to react to these symptoms, activate the EMS system, and expedite their arrival to an emergency room. In addition, more facilities must be able to provide primary PCI care, and, as was demonstrated in the C-PORT trials and the study published in this issue of CRM, surgical back up should not be mandatory . Primary PCI coverage is still a major limitation to access of care in rural areas. In addition to intensive patient education programs, efforts should be directed at building more cath labs and flying physicians and cath lab staff to take care of patients in these remote areas. Programs enabling in-the-field EKG transmissions should become more widely utilized to shorten the time to diagnosis and to initiate treatment. Perhaps these efforts are the next breakthrough in the management of STEMI.

Finally, we should not forget prevention. The number of patients presenting with STEMI has reduced, which may be attributed to the ongoing efforts of smoking cessation, LDL reduction and increased regular exercise. With the continued focus on such preventative measures and emerging therapies, cardiovascular mortality could be further reduced. Our efforts over the next decade should encompass all disciplines in order to focus on primary prevention and improved quality of care. This upstream approach can be achieved while we await the next breakthrough.