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Introduction: With the advent of reperfusion therapies, management of patients presenting with ST-elevation myocardial infarction (STEMI) has witnessed significant changes during the last decades., Aim: We sought to analyze temporal trends in reperfusion modalities and their prognostic impact over a 20-year period in patients presenting with STEMI the Monastir region (Tunisia)., Methods: Patients from Monastir region presenting for STEMI were included in a 20-year (1998-2017) single center registry. Reperfusion modalities, early and long-term outcomes were studied according to five four-year periods., Results: Out of 1734 patients with STEMI, 1370 (79%) were male and mean age was 60.3 ± 12.7 years. From 1998 to 2017, primary percutaneous coronary intervention (PCI) use significantly increased from 12.5% to 48.3% while fibrinolysis use significantly decreased from 47.6% to 31.7% (p<0.001 for both). Reperfusion delays for either fibrinolysis or primary PCI significantly decreased during the study period. In-hospital mortality significantly decreased from 13.7% during Period 1 (1998-2001) to 5.4% during Period 5 (2014-2017), (p=0.03). Long-term mortality rate (mean follow-up 49.4 ± 30.7 months) significantly decreased from 25.3% to 13% (p<0.001). In multivariate analysis, age, female gender, anemia on-presentation, akinesia/dyskinesia of the infarcted area and use of plain old balloon angioplasty were independent predictors of death at long-term follow-up whereas primary PCI use and preinfaction angina were predictors of long-term survival., Conclusions: In this long-term follow-up study of Tunisian patients presenting for STEMI, reperfusion delays decreased concomitantly to an increase in primary PCI use. In-hospital and long-term mortality rates significantly decreased from 1998 to 2017.

Competing Interests: The authors have no conflicts of interest to disclose.

Background Studies have reported significant reduction in acute myocardial infarction-related hospitalizations during the coronavirus disease 2019 (COVID-19) pandemic. However, whether these trends are associated with increased incidence of out-of-hospital cardiac arrest (OHCA) in this population is unknown. Methods and Results Acute myocardial infarction hospitalizations with OHCA during the COVID-19 period (February 1-May 14, 2020) from the Myocardial Ischaemia National Audit Project and British Cardiovascular Intervention Society data sets were analyzed. Temporal trends were assessed using Poisson models with equivalent pre-COVID-19 period (February 1-May 14, 2019) as reference. Acute myocardial infarction hospitalizations during COVID-19 period were reduced by >50% (n=20 310 versus n=9325). OHCA was more prevalent during the COVID-19 period compared with the pre-COVID-19 period (5.6% versus 3.6%), with a 56% increase in the incidence of OHCA (incidence rate ratio, 1.56; 95% CI, 1.39-1.74). Patients experiencing OHCA during COVID-19 period were likely to be older, likely to be women, likely to be of Asian ethnicity, and more likely to present with ST-segment-elevation myocardial infarction. The overall rates of invasive coronary angiography (58.4% versus 71.6%; P <0.001) were significantly lower among the OHCA group during COVID-19 period with increased time to reperfusion (mean, 2.1 versus 1.1 hours; P =0.05) in those with ST-segment-elevation myocardial infarction. The adjusted in-hospital mortality probability increased from 27.7% in February 2020 to 35.8% in May 2020 in the COVID-19 group ( P <.001). Conclusions In this national cohort of hospitalized patients with acute myocardial infarction, we observed a significant increase in incidence of OHCA during COVID-19 period paralleled with reduced access to guideline-recommended care and increased in-hospital mortality.

The improvement achieved in recent years in early myocardial infarction (MI) mortality poses several new clinical challenges, owing to late consequences of myocardial loss and the significant incidence of heart failure (HF) observed thereafter. A still unaddressed residual reperfusion injury (RI) contributes to final infarct size, acute MI mortality and longer-term HF development. Despite many cardioprotective lines of research in the setting of MI, no treatment has significantly altered clinical practice or convincingly improved outcomes either. Left ventricular mechanical unloading before culprit vessel reopening may reduce RI and prime (biologically and mechanically) the myocardium for reperfusion, thus limiting infarct size and preventing subsequent adverse remodeling. Aim of this review is to summarize key pre-clinical and clinical experiences furnishing a rationale to the approach of mechanical unloading before myocardial reperfusion with a translational outlook on its implications for the management of MI patients., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The increased use of reperfusion therapy in ST-segment-elevation myocardial infarction (STEMI) patients in the past decades is generally considered the main determinant of improved outcomes. The aim was to assess 20-year trends in profile, management, and one-year outcomes in STEMI patients in relation with use or non-use of reperfusion therapy (primary percutaneous coronary intervention (pPCI) or fibrinolysis)., Methods: We used data from 5 one-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 8579 STEMI patients (67% with and 33% without reperfusion therapy) admitted to cardiac intensive care units in France., Results: Use of reperfusion therapy increased from 49% in 1995 to 82% in 2015, with a shift from fibrinolysis (37.5% to 6%) to pPCI (12% to 76%). Early use of evidence-based medications gradually increased over the period in both patients with and without reperfusion therapy, although it remained lower at all times in those without reperfusion therapy. One-year mortality decreased in patients with reperfusion therapy (from 11.9% in 1995 to 5.9% in 2010 and 2015, hazard ratio [HR] adjusted on baseline profile 0.40; 95% CI: 0.29-0.54, P < .001) and in those without reperfusion therapy (from 25.0% to 18.2% in 2010 and 8.1% in 2015, HR: 0.33; 95% CI: 0.24-0.47, P < .001)., Conclusions: In STEMI patients, one-year mortality continues to decline, both related to increased use of reperfusion therapy and progress in overall patient management. In patients with reperfusion therapy, mortality has remained stable since 2010, while it has continued to decline in patients without reperfusion therapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To investigate whether prophylactic amiodarone infusion prevents ventricular fibrillation after aortic cross-clamp release and attenuates cytokine production in patients with left ventricular hypertrophy undergoing cardiac surgery., Design: Prospective, randomized controlled trial., Setting: A public hospital., Participants: The study comprised 68 patients undergoing aortic valve replacement for severe aortic stenosis., Interventions: Patients were randomly assigned to receive a 150mg bolus then 30mg/h continuous infusion of amiodarone (amiodarone group) or a 1 mg/kg bolus then 1 mg/kg/h continuous infusion of lidocaine (lidocaine group). The primary outcome was the ventricular fibrillation incidence rate after aortic cross-clamp release. Secondary outcomes included perioperative serum interleukin-6 and tumor necrosis factor-alpha levels., Measurements and Main Results: The ventricular fibrillation incidence rate was significantly lower in the amiodarone than in the lidocaine group (20.6% v 50%, relative risk 0.41; 95% confidence interval [CI] 0.20-0.86; p = 0.021). Interleukin-6 levels 1hour after aortic cross-clamp release and at intensive care unit admission were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 117.4pg/mL [87.1-158.4] v 339.5pg/mL [210.6-547.2]; p < 0.01 and 211.1pg/mL [162.8-73.6] v 434.1pg/mL [293.7-641.5]; p < 0.01, respectively). Tumor necrosis factor-alpha levels 1hour after aortic cross-clamp release were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 1.624pg/mL [1.359-1.940] v 2.283pg/mL [1.910-2.731]; p = 0.02)., Conclusions: Amiodarone prevented reperfusion ventricular fibrillation in patients with left ventricular hypertrophy undergoing aortic valve replacement to a greater extent than did lidocaine. Furthermore, amiodarone inhibited postoperative interleukin-6 and tumor necrosis factor-alpha production., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Heart failure after an acute myocardial infarction (AMI) is a major cause of morbidity and mortality worldwide. We recently reported that activation of a transvalvular axial-flow pump in the left ventricle and delaying myocardial reperfusion, known as primary unloading, limits infarct size after AMI. The mechanisms underlying the cardioprotective benefit of primary unloading and whether the acute decrease in infarct size results in a durable reduction in LV scar and improves cardiac function remain unknown., Objectives: This study tested the importance of LV unloading before reperfusion, explored cardioprotective mechanisms, and determined the late-term impact of primary unloading on myocardial function., Methods: Adult male swine were subjected to primary reperfusion or primary unloading after 90 min of percutaneous left anterior descending artery occlusion., Results: Compared with primary reperfusion, 30 min of LV unloading was necessary and sufficient before reperfusion to limit infarct size 28 days after AMI. Compared with primary reperfusion, primary unloading increased expression of genes associated with cellular respiration and mitochondrial integrity within the infarct zone. Primary unloading for 30 min further reduced activity levels of proteases known to degrade the cardioprotective cytokine, stromal-derived factor (SDF)-1α, thereby increasing SDF-1α signaling via reperfusion injury salvage kinases, which limits apoptosis within the infarct zone. Inhibiting SDF-1α activity attenuated the cardioprotective effect of primary unloading. Twenty-eight days after AMI, primary unloading reduced LV scar size, improved cardiac function, and limited expression of biomarkers associated with heart failure and maladaptive remodeling., Conclusions: The authors report for the first time that first mechanically reducing LV work before coronary reperfusion with a transvalvular pump is necessary and sufficient to reduce infarct size and to activate a cardioprotective program that includes enhanced SDF-1α activity. Primary unloading further improved LV scar size and cardiac function 28 days after AMI., (Copyright © 2018. Published by Elsevier Inc.)

Aims: In STEMI patients, success of reperfusion of primary PCI predicts cardiac remodeling and clinical outcome. This success may depend on inflammation. We aimed to investigate the association between inflammation and reperfusion success, left ventricular function and long-term mortality in STEMI patients., Methods: In 376 consecutive STEMI patients of the GIPS-III trial hs-CRP levels were measured at baseline, 2weeks, 7weeks and 4months post-PCI. Myocardial blush grade was used to determine success of myocardial reperfusion. In multivariate models sex, age, hs-CRP levels at baseline, NT-proBNP levels at baseline, ischemia time, heart rate, TIMI flow, and CK, CKMB and troponin AUC were included. Follow-up was complete until 4months., Results: Baseline hs-CRP levels were 2.1mg/l (IQR 0.5-4.2mg/l). hs-CRP levels were associated with impaired reperfusion (OR 1.239, 95% CI 1.006-1.527) and remained higher compared to patients with normal reperfusion up to 2months after PCI (hs-CRP 1.9mg/l (IQR 0.9-3.7mg/l) versus 1.5mg/l (IQR 0.7-2.7mg/l), p=0.041). In multivariate analysis baseline hs-CRP levels remained independently associated with impaired reperfusion. In patients with impaired reperfusion, hs-CRP and NT-proBNP levels remained higher during 4months of follow-up. No correlation was observed between hs-CRP at baseline and left ventricular function at 4months. The number of events was small and we observed no differences in mortality., Conclusion: Increased hs-CRP levels at presentation are associated with impaired microvascular reperfusion after PCI in STEMI patients and remain higher until 2months follow-up., (Copyright © 2017. Published by Elsevier B.V.)

Aims: To perform a systematic review and meta-analysis of randomized clinical trials (RCT) comparing the effectiveness of drugs targeting mitochondrial function vs. placebo in patients with ST-segment elevation myocardial infarction (STEMI) undergoing mechanical coronary reperfusion., Methods: Inclusion criteria: RCTs enrolling STEMI patients treated with primary percutaneous coronary intervention (PCI) and comparing drugs targeting mitochondrial function vs. placebo. Odds ratios (OR) were computed from individual studies and pooled with random-effect meta-analysis., Results: Fifteen studies were identified involving 5680 patients. When compared with placebo, drugs targeting mitochondrial component/pathway were not associated with significant reduction of cardiovascular and all-cause mortality (OR 0.9, 95% CI 0.7-1.17 and OR 0.92, 95% CI 0.69-1.23, respectively). However, these agents significantly reduced hospital admission for heart failure (HF) (OR 0.64; 95% CI 0.45-0.92) and increased left ventricular ejection fraction (LVEF) (OR 1.44; 95% CI 1.15-1.82). After analysis for subgroups according to the mechanism of action, drugs with direct/selective action did not reduce any outcome. Conversely, those with indirect/unspecific action showed a significant effect on cardiovascular mortality (0.65, 95% CI 0.46-0.92), all-cause mortality (OR 0.69, 95% CI 0.52-0.92), hospital readmission for HF (OR 0.41, 95% CI 0.28-0.6) and LVEF (OR 1.49, 95% CI 1.09-2.05)., Conclusions: Administration of drugs targeting mitochondrial function in STEMI patients undergoing primary PCI appear to have no effect on mortality, but may reduce hospital readmission for HF. The drugs with a broad-spectrum mechanism of action seem to be more effective in reducing adverse events., (Copyright © 2017 Elsevier B.V. All rights reserved.)

For >4 decades, the holy grail in the treatment of acute myocardial infarction has been the mitigation of lethal injury. Despite promising initial results and decades of investigation by the cardiology research community, the only treatment with proven efficacy is early reperfusion of the occluded coronary artery. The remarkable record of failure has led us and others to wonder if cardioprotection is dead. The path to translation, like the ascent to Everest, is certainly littered with corpses. We do, however, highlight a therapeutic principle that provides a glimmer of hope: cellular postconditioning. Administration of cardiosphere-derived cells after reperfusion limits infarct size measured acutely, while providing long-term structural and functional benefits. The recognition that cell therapy may be cardioprotective, and not just regenerative, merits further exploration before we abandon the pursuit entirely., (© 2017 American Heart Association, Inc.)

Introduction and Objectives: To analyze the association between the development of network systems of care for ST-segment elevation myocardial infarction (STEMI) in the autonomous communities (AC) of Spain and the regional rate of percutaneous coronary intervention (PCI) and in-hospital mortality., Methods: From 2003 to 2012, data from the minimum basic data set of the Spanish taxpayer-funded health system were analyzed, including admissions from general hospitals. Diagnoses of STEMI and related procedures were codified by the International Diseases Classification. Discharge episodes (n = 302 471) were distributed in 3 groups: PCI (n = 116 621), thrombolysis (n = 46 720), or no reperfusion (n = 139 130)., Results: Crude mortality throughout the evaluation period was higher for the no-PCI or thrombolysis group (17.3%) than for PCI (4.8%) and thrombolysis (8.6%) (P < .001). For the aggregate of all communities, the PCI rate increased (21.6% in 2003 vs 54.5% in 2012; P < .001) with a decrease in risk-standardized mortality rates (10.2% in 2003; 6.8% in 2012; P < .001). Significant differences were observed in the PCI rate across the AC. The development of network systems was associated with a 50% increase in the PCI rate (P < .001) and a 14% decrease in risk-standardized mortality rates (P < .001)., Conclusions: From 2003 to 2012, the PCI rate in STEMI substantially increased in Spain. The development of network systems was associated with an increase in the PCI rate and a decrease in in-hospital mortality., (Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Acute myocardial infarction has traditionally been divided into ST elevation or non-ST elevation myocardial infarction; however, therapies are similar between the two, and the overall management of acute myocardial infarction can be reviewed for simplicity. Acute myocardial infarction remains a leading cause of morbidity and mortality worldwide, despite substantial improvements in prognosis over the past decade. The progress is a result of several major trends, including improvements in risk stratification, more widespread use of an invasive strategy, implementation of care delivery systems prioritising immediate revascularisation through percutaneous coronary intervention (or fibrinolysis), advances in antiplatelet agents and anticoagulants, and greater use of secondary prevention strategies such as statins. This seminar discusses the important topics of the pathophysiology, epidemiological trends, and modern management of acute myocardial infarction, focusing on the recent advances in reperfusion strategies and pharmacological treatment approaches., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: China is experiencing a marked increase in ST-segment elevation myocardial infarction hospitalizations, with 30% occurring among women and higher risk of in-hospital death in relatively younger age groups (<70). Yet, little is known about sex differences in ST-segment elevation myocardial infarction presentation and management., Methods and Results: In a nationally representative sample of patients with ST-segment elevation myocardial infarction admitted to 162 Chinese hospitals in 2001, 2006, and 2011, we examined sex differences in hospitalization rates, clinical profiles, and quality of care. Among 11 986 patients, the proportion of women was unchanged between 2001 and 2011. The estimated national rates of hospital admission per 100 000 people increased from 4.6 in 2001 to 18.0 in 2011 among men (3.9-fold increase) and from 1.9 to 8.0 among women (4.2-fold increase) (Ptrend<0.0001). The median age of women increased from 68 years in 2001 to 72 years in 2011 (Ptrend<0.001); however, there was no age change in men (63 years in 2011) (Ptrend=0.48). After accounting for age, women had a higher frequency of comorbidities. Although there were significant sex differences in the time interval of >12 hours between symptom onset and admission time in 2001, since 2006 delays in presentation were comparable between women and men. Fewer women without contraindications received evidence-based therapies than men, including reperfusion (57.5% versus 44.2%), early aspirin (88.8% versus 85.9%), and clopidogrel (56.9% versus 52.5%, P<0.001 for all) and the differences were largely unchanged over time., Conclusions: Women experienced a higher increase in hospitalization rates for ST-segment elevation myocardial infarction in China between 2001 and 2011 and were less likely to receive evidence-based therapies, especially reperfusion. In addition to efforts to improve quality of care generally, understanding the reasons for this sex disparity and addressing these differences in care should be a priority., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

The damage inflicted on the myocardium during acute myocardial infarction is the result of 2 processes: ischemia and subsequent reperfusion (ischemia/reperfusion injury). During the last 3 decades, therapies to reduce ischemic injury (mainly reperfusion strategies) have been widely incorporated into clinical practice. The remarkable reduction in death rates achieved with these therapies has resulted in a shift in emphasis from efforts to reduce mortality to a focus on tackling the downstream consequence of survival: post-infarction heart failure. Infarct size is the main determinant of long-term mortality and chronic heart failure, and thus, the possibility of limiting the extent of necrosis during an ST-segment elevation myocardial infarction is of great individual and socioeconomic value. After the great success of therapies to reduce ischemic injury, the time has come to focus efforts on therapies to reduce reperfusion injury, but in the recent few years, few interventions have successfully passed the proof-of-concept stage. In this review, we examine the past, present, and future therapies to reduce ischemia/reperfusion injury., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We investigated the effects of intracoronary transplantation of CD34(+) cells on myocardial perfusion in patients with nonischemic dilated cardiomyopathy (DCM)., Methods and Results: We enrolled 21 patients with DCM (left ventricular ejection fraction [LVEF] <40%, New York Heart Association functional class III) who underwent peripheral stem cell mobilization with granulocyte-colony stimulating factor (G-CSF). CD34(+) cells were collected by means of apheresis. Patients underwent myocardial perfusion imaging, and CD34(+) cells were injected in the coronary artery supplying viable segments with reduced myocardial perfusion and regional dysfunction. Myocardial perfusion imaging was repeated 6 months later. Clinical response to stem cell therapy was predefined as a change in LVEF >5%. The majority of patients were men (81%) with an overall mean age 53 ± 9 years, LVEF 25 ± 5%, and 6-minute walking distance 354 ± 71 m. Myocardial perfusion defects at rest were observed in 86% of patients and were more common in the left anterior descending territory (50%). At 6 months' follow-up, there was a significant improvement in rest myocardial perfusion scores (6.3 ± 5.8 vs 3.1 ± 4.3; P < .001), LVEF (25 ± 7% vs 29 ± 8%; P = .005), and 6-minute walking distance (354 ± 71 m vs 404 ± 91 m; P < .001). Responders to stem cell therapy had lower summed rest perfusion score at both baseline (3.2 ± 3.0 vs 9.1 ± 6.3; P = .015) and follow-up (1.0 ± 1.5 vs 5.0 ± 5.1; P = .028)., Conclusions: CD34(+) cell transplantation may lead to improved myocardial perfusion in patients with nonischemic DCM. Patients with less severe myocardial perfusion defects at baseline may have an increased likelihood to respond to intracoronary CD34(+) cell transplantation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Socioeconomic status (SES) as reflected by residential zip code status may detrimentally influence a number of prehospital clinical, access-related, and transport variables that influence outcome for patients with ST-elevation myocardial infarction (STEMI) undergoing reperfusion. We sought to analyze the impact of SES on in-hospital mortality, timely reperfusion, and cost of hospitalization following STEMI., Methods and Results: We used the 2003-2011 Nationwide Inpatient Sample database for this analysis. All hospital admissions with a principal diagnosis of STEMI were identified using ICD-9 codes. SES was assessed using median household income of the residential zip code for each patient. There was a significantly higher mortality among the lowest SES quartile as compared to the highest quartile (OR [95% CI]: 1.11 [1.06 to 1.17]). Similarly, there was a highly significant trend indicating a progressively reduced timely reperfusion among patients from lower quartiles (OR [95% CI]: 0.80 [0.74 to 0.88]). In addition, there was a lower utilization of circulatory support devices among patients from lower as compared to higher zip code quartiles (OR [95% CI]: 0.85 [0.75 to 0.97]). Furthermore, the mean adjusted cost of hospitalization among quartiles 2, 3, and 4, as compared to quartile 1 was significantly higher by $913, $2140, and $4070, respectively., Conclusions: Patients residing in zip codes with lower SES had increased in-hospital mortality and decreased timely reperfusion following STEMI as compared to patients residing in higher SES zip codes. The cost of hospitalization of patients from higher SES quartiles was significantly higher than those from lower quartiles., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Ischemic postconditioning (PCON) appears as a potentially beneficial tool in ST-segment elevation myocardial infarction (STEMI). We evaluated the effect of PCON on microvascular obstruction (MVO) in STEMI patients and in an experimental swine model., Methods: A prospective randomized study in patients and an experimental study in swine were carried out in two university hospitals in Spain. 101 consecutive STEMI patients were randomized to undergo primary angioplasty followed by PCON or primary angioplasty alone (non-PCON). Using late gadolinium enhancement cardiovascular magnetic resonance, infarct size and MVO were quantified (% of left ventricular mass). In swine, using an angioplasty balloon-induced anterior STEMI model, MVO was defined as the % of area at risk without thioflavin-S staining., Results: In patients, PCON (n=49) in comparison with non-PCON (n=52) did not significantly reduce MVO (0 [0-1.02]% vs. 0 [0-2.1]% p=0.2) or IS (18 ± 13% vs. 21 ± 14%, p=0.2). MVO (>1 segment in the 17-segment model) occurred in 12/49 (25%) PCON and in 18/52 (35%) non-PCON patients, p=0.3. No significant differences were observed between PCON and non-PCON patients in left ventricular volumes, ejection fraction or the extent of hemorrhage. In the swine model, MVO occurred in 4/6 (67%) PCON and in 4/6 (67%) non-PCON pigs, p=0.9. The extent of MVO (10 ± 7% vs. 10 ± 8%, p=0.9) and infarct size (23 ± 14% vs. 24 ± 10%, p=0.8) was not reduced in PCON compared with non-PCON pigs., Conclusions: Ischemic postconditioning does not significantly reduce microvascular obstruction in ST-segment elevation myocardial infarction. Clinical Trial Registration http://www.clinicaltrials.gov. Unique identifier: NCT01898546., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Although primary percutaneous coronary intervention (pPCI) is the preferred reperfusion method for ST-segment-elevation myocardial infarction, it remains difficult to implement in many areas, and fibrinolytic therapy is still widely used., Methods and Results: We assessed 5-year mortality in patients with ST-segment-elevation myocardial infarction from the French Registry of Acute ST-Elevation or Non-ST Elevation Myocardial Infarction (FAST-MI) 2005 according to use and type of reperfusion therapy. Of 1492 patients with ST-segment-elevation myocardial infarction with a first call ≤12 hours from onset, 447 (30%) received fibrinolysis (66% prehospital; 97% with subsequent angiography, 84% with subsequent PCI), 583 (39%) had pPCI, and 462 (31%) received no reperfusion. Crude 5-year survival was 88% for the fibrinolytic-based strategy, 83% for pPCI, and 59% for no reperfusion. Adjusted hazard ratios for 5-year death were 0.73 (95% confidence interval, 0.50-1.06) for fibrinolysis versus pPCI, 0.57 (95% confidence interval, 0.36-0.88) for prehospital fibrinolysis versus pPCI, and 0.63 (95% confidence interval, 0.34-0.91) for fibrinolysis versus pPCI beyond 90 minutes of call in patients having called ≤180 minutes from onset. In propensity score-matched populations, however, survival rates were not significantly different for fibrinolysis and pPCI, both in the whole population (88% lysis, 85% pPCI) and in the population seen early (87% fibrinolysis, 85% pPCI beyond 90 minutes from call)., Conclusions: In a real-world setting, on a nationwide scale, a pharmaco-invasive strategy constitutes a valid alternative to pPCI, with 5-year survival at least equivalent to that of the reference reperfusion method., Clinical Trial Registration Url: www.clinicaltrials.gov. Unique identifier: NCT00673036.

Over the past five decades, management of acute ST-segment elevation myocardial infarction (STEMI) has evolved substantially. Current treatment encompasses a systematic chain of network activation, antithrombotic drugs, and rapid instigation of mechanical reperfusion, although pharmacoinvasive strategies remain relevant. Secondary prevention with drugs and lifestyle modifications completes the contemporary management package. Despite a tangible improvement in outcomes, STEMI remains a frequent cause of morbidity and mortality, justifying the quest to find new therapeutic avenues. Ways to reduce delays in doing coronary angioplasty after STEMI onset include early recognition of symptoms by patients and prehospital diagnosis by paramedics so that the emergency room can be bypassed in favour of direct admission to the catheterisation laboratory. Mechanical reperfusion can be optimised by improvements to stent design, whereas visualisation of infarct size has been improved by developments in cardiac MRI. Novel treatments to modulate the inflammatory component of atherosclerosis and the vulnerable plaque include use of bioresorbable vascular scaffolds and anti-proliferative drugs. Translational efforts to improve patients' outcomes after STEMI in relation to cardioprotection, cardiac remodelling, and regeneration are also being realised., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI., Methods: Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression., Results: Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes., Conclusion: The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background and Purpose: Early reperfusion is the most effective therapy for both acute brain and cardiac ischemia. However, the cervicocephalic circulatory bed offers more challenges to recanalization interventions. The historical development of reperfusion interventions has not previously been systematically compared., Methods: Medline search identified all multi-arm, controlled trials of coronary revascularization for acute myocardial infarction and multicenter trials of cerebral revascularization for acute ischemic stroke reporting angiographic reperfusion rates., Results: Thirty-seven trials of coronary reperfusion enrolled 10 908 patients from 1983 to 2009, and 10 trials of cerebral reperfusion enrolled 1064 patients from 1992 to 2009. Coronary reperfusion trials included 10 of intravenous fibrinolysis alone, 8 combined intravenous fibrinolysis and percutaneous transluminal coronary angioplasty with or without stenting, 3 intra-arterial fibrinolysis, and 16 percutaneous transluminal coronary angioplasty with or without stenting. Cerebral reperfusion trials included 1 of intravenous fibrinolysis alone, 3 intra-arterial fibrinolysis, 3 endovascular device alone, and 3 of endovascular treatment ± intravenous fibrinolysis. In both circulatory beds, endovascular treatments were more efficacious at achieving reperfusion than peripherally administered fibrinolytics. In the coronary bed, rates of achieved reperfusion began at high levels in the 1980s and improved modestly over the subsequent 3 decades. In the cerebral bed, reperfusion rates began at modest levels in the early 1990s and increased more slowly. Most recently, in 2005 to 2009, cardiac reperfusion rates substantially exceeded cerebral, partial reperfusion 86.1% versus 61.1%, complete reperfusion 78.6% versus 23.4%., Conclusions: Reperfusion therapies developed more slowly and remain less effective for cerebral than cardiac ischemia. Further, cerebral circulation-specific technical advances are required for physicians to become as capable at safely restoring blood flow to the ischemic brain as the ischemic heart.

Aims: In India, larger proportions of patients with ACS present with STEMI. We sought to study the recent trends of reperfusion in patients of acute STEMI., Methods and Results: 1905 patients presenting with acute STEMI enrolled. 1636 (86%) received some form of reperfusion therapy. Streptokinase, 1235 (65%) patients, was the most common mode of reperfusion therapy used followed by primary PCI (205, 10.7%) and tenecteplase (196, 10%). 269 (14%) did not receive any form of reperfusion therapy, the most common reason being late presentation in 230 (85.7%). Patients presenting with STEMI increased from 297 to 446 comparing first and last half-year of study period. The PCI and tenecteplase numbers increased from 19 to 68 and 27 to 97 respectively., Conclusion: There was 20% increase in STEMI every year. Younger patients are least likely to receive primary PCI or tenecteplase. 1 in 8 patients of STEMI did not receive any form of reperfusion therapy., (Copyright © 2012 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Coronary thrombolytic therapy was first introduced for patients with acute myocardial infarction (AMI) during the early 1980s in Japan. Several modalities have been developed and primary percutaneous intervention with stent is the current preferred strategy for patients with AMI., Methods and Results: From May 1981 to December 2010, 2782 patients with AMI underwent coronary angiography within 24h after the onset of symptoms at Hiroshima City Hospital. Patients were divided into 6 groups in chronological order. Thrombolysis was most frequently performed in the early 1980s. Balloon angioplasty became the most frequent choice in the late 1980s and angioplasty with stents in the late 1990s. Final thrombolysis in myocardial infarction-3 flow was obtained in only 39% in the early 1980s, which progressively increased to 93% in the late 2000s. In-hospital mortality was >10% in the 1980s, which decreased by half in the late 1990s. Post-infarction angina occurred in 30% in the early 1980s. It rapidly decreased, occurring in <1% in the 2000s. Reinfarction occurred in 8.8% in the late 1980s which decreased to <3% in the 2000s. The incidence of congestive heart failure remained unchanged ranging approximately from 5% to 10% until the early 2000s, which decreased to 2.8% in the late 2000s., Conclusion: Over the past 30 years, modality of reperfusion therapy has changed from thrombolysis to balloon angioplasty and further to angioplasty with stents. As the reperfusion rate increased, in-hospital outcomes after AMI have improved., (Copyright © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Study Objective: Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE])., Methods: We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality., Results: From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions)., Conclusion: The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Despite being the most effective means of limiting infarct size, coronary reperfusion comes at a price and induces additional damage to the myocardium. Lethal reperfusion injury (death of myocytes that were viable at the time of reperfusion) is an increasingly acknowledged phenomenon. There are many interconnected mechanisms involved in this type of cell death. Calcium overload (generating myocyte hypercontracture), rapid recovery of physiological pH, neutrophil infiltration of the ischemic area, opening of the mitochondrial permeability-transition-pore (PTP), and apoptotic cell death are among the more important mechanisms involved in reperfusion injury. The activation of a group of proteins called reperfusion injury salvage kinases (RISK) pathway confers protection against reperfusion injury, mainly by inhibiting the opening of the mitochondrial PTP. Many interventions have been tested in human trials triggered by encouraging animal studies. In the present review we will explain in detail the main mechanism involved in reperfusion injury, as well as the various approaches (pre-clinical and human trials) performed targeting these mechanisms. Currently, no intervention has been consistently shown to reduce reperfusion injury in large randomized multicenter trials, but the research in this field is intense and the future is highly promising., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

ST elevation myocardial infarction (STEMI) is related to acute occlusion of a coronary artery by a fibrin reach thrombus. Early reperfusion may reduce infarct size and improve prognosis. Percutaneous coronary intervention (PCI) is more effective than intravenous fibrinolysis (IVF). Fibrinolysis remains useful in patients when PCI is not feasible. IVF has largely contributed to the knowledge of the physiopathology of STEMI and its management., (Copyright © 2011. Published by Elsevier Masson SAS.)

Background: TIMI myocardial perfusion grade (TMPG) reflects the integrity of microvasculature in ST-elevation myocardial infarction (STEMI). We sought to investigate whether TMPG evolution during primary angioplasty (pPCI) in spontaneously reperfused STEMI patients might predict long-term outcomes., Methods: 392 patients with TIMI-3 flow before pPCI were analyzed. According to pre- and post-pPCI TMPG four reperfusion patterns were created: A. TMPG deterioration from grade 2/3 to 0/1 after pPCI (n = 55, 14.0%), B. TMPG-0/1 before and after pPCI (n = 111, 28.3%), C. TMPG improvement from grade 0/1 to 2/3 (n = 52, 13.3%), D. TMPG-2/3 before and after pPCI (n = 174, 44.4%). 30-day and 1-year mortality and heart failure requiring hospitalization (HF-hosp) were recorded. Left ventricular ejection fraction (LVEF) was measured at first day (1D) and after 6 months (6M)., Results: 1D-LVEF was similar in A-D groups. After 6M, LVEF improved in pattern D (7.5 ± 5.4%, p<0.01) and C (3.7 ± 3.4%, p < 0.05), deteriorated in pattern A (5.2 ± 3.9%, p<0.01) and did not change in pattern B. 6M-LVEF increased (p < 0.001) and frequency of 1-year HF-hosp decreased (p < 0.001) in stepwise fashion among A-D patterns. A 30-day mortality rate for A-D patterns was 9.1%, 2.7%, 1.9% and 0%, respectively (p < 0.001). 1-year mortality was 16.3%, 7.2%, 5.8% and 0.6%, respectively (p < 0.001). By multivariate analysis (c-index = 0.79), TMPG evolution was independent predictor of 1-year mortality (HR = 2.5, 95%CI 1.3-4.0, p = 0.006)., Conclusions: Maintaining TMPG-2/3 or improving TMPG-0/1 through pPCI in STEMI implies LV function recovery and good long-term survival. In contrast, substantial deterioration of TMPG is associated with lack of LV function recovery, and the highest mortality rate., (Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.)

Background: A substantial progress has been made in Poland in the field of acute coronary syndromes (ACS) management over the last 10 years., Aim: To present the data from the Polish Registry of Acute Coronary Syndromes (PL-ACS) collected between 2003 and 2009. Changes in treatment strategies and outcomes in ST-segment myocardial infarction (STEMI) were analysed., Methods: We analysed patients enrolled to the PL-ACS Registry - a nationwide multicenter, prospective observational study of consecutive patients hospitalised with ACS in Poland., Results: Overall, 284,162 patients with ACS were enrolled in 512 centres including 88 invasive cardiology centres. The STEMI was diagnosed in 35-36% of these patients in 2003-2005, and this proportion remained stable at 30% to 32% in 2006-2009. The mean age of STEMI patients increased from 62.5 years in 2003 to 64.5 in 2009. During this period, women represented 32.7% to 34.6% of the STEMI patients. Proportion of patients presenting with pulmonary oedema or cardiogenic shock decreased with time, from 15.5% in 2003 to 8% in 2009. Delays to reperfusion tended to reduce over time: pain-to- -admission time was 240 min in 2005 and 229 min in 2009 and door-to-balloon time was 32 and 25 min in 2005 and 2009, respectively, with the delay being longer in the elderly population. The proportion of patients undergoing coronary angiography showed a constant increase, from 55% in 2003 to 84% in 2009. Percutaneous coronary intervention was performed in 51% and 78% of patients in 2003 and 2009, respectively. At the same time, the proportion of patients undergoing thrombolysis declined from 14% to 1%. Aspirin, beta-blocker, statin and ACE inhibitor use was constantly high, while nitrate use declined from 82% to 15%. The proportion of patients receiving clopidogrel increased from 40% to 97% over the analysed period. Significant reductions in mortality rates were observed: in-hospital mortality decreased from 11.9% to 6.4%; 30-day mortality from 13.5% to 9.6%; and 12-month mortality from 19.8% to 15.4% in 2003 and 2009, respectively. Invasive treatment strategy was associated with better in-hospital and long-term patient survival., Conclusions: The PL-ACS Registry results demonstrate low short- and long-term mortality rates in STEMI patients, mainly due to frequent use of interventional strategy, satisfactory logistics and appropriate drug therapy used. As a consequence, hospitalisation time has shortened. However, there are several issues that need to be improved such as shortening of pre- -hospital delays and increasing the rate of invasive treatment in patients presenting with cardiogenic shock.

Background: Current guidelines propose different reperfusion strategies for ST-elevation myocardial infarction (STEMI) depending on the time delay from pain onset, the availability of a catheterization laboratory and the patient's characteristics. In order to implement national strategies to improve reperfusion rates the existing situation must be first analysed. The aim of this report is to provide a description of where and when STEMI patients present in a countrywide registry., Methods: The Hellenic Infarction Observation Study (HELIOS) was a countrywide registry that enrolled 1096 patients with STEMI from 31 hospitals with a proportional representation of all types of hospitals from all geographical areas. We recorded the proportion of patients that fits within each category of treatment algorithms., Results: The following percentages of the total STEMI population were recorded: a) admitted in invasive hospitals within 12 h 28.7% (with 26% of those not reperfused) and after 12 h 5.9% and b) admitted in non-invasive hospitals within 3 h 34.9% (with 30% of those not reperfused), 3-12 h 19.3% and after 12 h 11%., Conclusions: A large proportion of STEMI patients are admitted either in an invasive hospital within 12 h or in a non-invasive one within 3 h from pain onset and therefore can be treated locally according to the guidelines. A relatively small percentage of patients are late presenters in non-invasive centres and are candidates for immediate transfer for primary PCI. These data could be useful in planning reperfusion strategies at countrywide level since not all patients may require immediate transfer for primary PCI., (Copyright (c) 2008 Elsevier Ireland Ltd. All rights reserved.)

Background: The objectives of our study were to examine long-term (1986-2003) trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized at all Central Massachusetts medical centers with acute myocardial infarction (AMI). Our secondary study goal was to examine factors associated with use of these coronary reperfusion strategies. Limited contemporary data are available about changing trends in the use of coronary reperfusion strategies, particularly from a population-based perspective., Methods: The sample consisted of 9422 greater Worcester (MA) residents hospitalized with AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003., Results: Divergent trends in the use of PCI and thrombolytic therapy during hospitalization for AMI were noted. Use of thrombolytic therapy increased after its introduction to clinical practice in the mid-1980s through the early 1990s with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. Marked increases in the use of PCI during hospitalization for AMI were noted over time. In 2003, 42.1% of patients with AMI received a PCI. Several demographic and clinical factors were associated with the use of these different treatment strategies., Conclusions: The results of our study in a large New England (United States) community suggest evolving changes in the hospital management of patients with AMI. Current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery.

Aim: Many patients who are eligible for acute reperfusion therapy receive it after substantial delays or not at all. We wanted to determine whether over the years more patients are receiving reperfusion therapy., Methods and Results: This analysis is based on 10 954 patients with ST elevation or left bundle-branch block presenting within 12 h of symptom onset and enrolled in the GRACE registry between April 1999 and June 2006. Over this time, there was an increasing trend in use of primary percutaneous coronary intervention (PCI) from 15% to 44% (P < 0.001), while use of fibrinolytic therapy decreased (from 41 to 16%; P < 0.01). No trend in median time to primary PCI was seen but that for fibrinolysis declined significantly (from 40 to 34%; P < 0.0001). Hospital mortality declined (6.9-5.4%; P < 0.01); the relationship between observed and expected mortality improved over time (P = 0.06). Nevertheless, 33% of patients still received no reperfusion therapy. Factors associated with reperfusion use included age; prior myocardial infarction, heart failure or coronary artery bypass graft surgery; history of diabetes; female sex; and delay from symptom onset to hospital arrival. In 2006, 52% of patients receiving fibrinolysis had door-to-needle times >30 min and 42% of those undergoing primary PCI had door-to-balloon times >90 min., Conclusion: Primary PCI is now used much more than fibrinolysis. Although hospital mortality and delays to fibrinolytic reperfusion have improved, over 40% of patients reperfused still receive it outside the time window recommended, and one-third of potentially eligible patients receive no reperfusion.

Background: The objectives of our study were to examine long-term (1986-2003) trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized with acute myocardial infarction (AMI) while our secondary study goal was to examine factors associated with use of these coronary reperfusion strategies. While there have been considerable changes in the management of patients hospitalized with AMI over time, limited contemporary data are available about changing trends in the use of different coronary reperfusion strategies, particularly from the more generalizable perspective of a population-based investigation., Methods: The study sample consisted of 9,422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003., Results: Divergent trends in the use of PCI and thrombolytic therapy during hospitalization for AMI were noted. Use of thrombolytic therapy increased after its introduction to clinical practice in the mid-1980's through the early 1990's with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. On the other hand, marked increases in the use of PCI during hospitalization for AMI were noted over time. In 2003, 42.1% of patients with AMI received a PCI. Several demographic and clinical factors were associated with the use of these different treatment strategies., Conclusions: The results of our study in a large Northeast community suggest evolving changes in the hospital management of patients with AMI. Current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery.

Objective: To document the trends in reperfusion therapy for ST segment elevation myocardial infarction (STEMI) in Switzerland., Design: National prospective multicentre registry, AMIS Plus (acute myocardial infarction and unstable angina in Switzerland), of patients admitted with acute coronary syndromes., Setting: 54 hospitals of varying size and capability in Switzerland., Patients: 7098 of 11 845 AMIS Plus patients who presented with ST segment elevation or left bundle branch block on the ECG at admission., Main Outcome Measures: In-hospital mortality and its predictors at admission by multivariate analysis., Results: The proportion of patients treated by primary percutaneous coronary intervention (PCI) progressively increased from 1997 to 2002, while the proportion with thrombolysis or no reperfusion decreased (from 8.0% to 43.1%, from 47.2% to 25.6%, and from 44.8% to 31.4%, respectively). Overall in-hospital mortality decreased over the study period from 12.2% to 6.7% (p < 0.001). Main in-hospital mortality predictors by multivariate analysis were primary PCI (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.33 to 0.81), thrombolysis (OR 0.63, 95% CI 0.47 to 0.83), and Killip class III (OR 3.61, 95% CI 2.49 to 5.24) and class IV (OR 5.97, 95% CI 3.51 to 10.17) at admission. When adjusted for the year, multivariate analysis did not show PCI to be significantly superior to thrombolysis for in-hospital mortality (OR 1.2 for PCI better, 95% CI 0.8 to 1.9, p = 0.42)., Conclusion: Primary PCI has become the preferred mode of reperfusion for STEMI since 2002 in Switzerland, whereas use of intravenous thrombolysis has decreased from 1997 to 2002. Furthermore, there was a major reduction of in-hospital mortality over the same period.

The optimal reperfusion strategy in elderly patients with ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. This lack of consensus stems from the exclusion or under-representation of the elderly in clinical trials. This review evaluates the available literature pertaining to reperfusion therapy for the treatment of STEMI in the elderly. We identified all published studies evaluating the effectiveness of thrombolytic therapy, primary percutaneous coronary intervention (PCI), or adjunctive therapies to reperfusion by conducting an electronic search of MEDLINE through December 2003. Meta-analysis of clinical trials suggests a survival benefit of thrombolytic therapy in the elderly with STEMI, whereas some observational studies have raised concerns about the lack of short-term benefit or possibility of harm with thrombolysis. However, most observational studies demonstrate improved intermediate-term survival with thrombolysis. In contrast, multiple clinical trials and observational studies indicate improved survival and low risk of stroke with primary PCI compared with thrombolysis in elderly patients with STEMI. Information on the efficacy of newer antithrombotic agents as adjunct to thrombolysis or primary PCI is scarce. Available data suggest an increased risk of intracerebral bleeding with the combination of a fibrin-specific agent and a glycoprotein IIb/IIIa receptor antagonist in patients >75 years of age. Clearly targeted large-scale clinical trials are needed to evaluate the relative merits of available reperfusion strategies as well as newer antithrombotic adjunctive therapies in the elderly with STEMI.

Retroinfusion of the coronary veins has gained attention for therapeutic approaches which target drugs, genes or cells to ischemic myocardium. Besides anatomy of the coronary venous system, the pressure flow relationship during retroinfusion and the efficacy of pressure-regulated selective retroinfusion for targeted delivery of drugs is reported. Moreover, we describe adenoviral and liposomal gene transfer into ischemic and nonischemic myocardium, outline studies in chronic ischemic preclinical models treated by retroinfusion of pro-angiogenic agents and discuss the impact of retroinfusion for cell-based regenerative therapy of the diseased myocardium.

Cardiac surgeons are commonly faced with issues regarding the balance between the potential risk and the potential benefit of a surgical procedure. Nuclear cardiology procedures [myocardial perfusion SPECT (MPS) and positron emission tomography (PET)] provide the surgeon with objective information that augments standard clinical and angiographic assessments with respect to diagnosis, prognosis, and potential benefit from intervention. Development of the technology and methodology of gated MPS acquisition and interpretation allows assessment of the extent and severity of hypoperfused but viable myocardium, as well as global LVEF and LV volume measurements, diastolic function, and LV geometry. With PET, myocardial metabolism and blood flow reserve can also be measured. This chapter provides insight into the current evidence regarding settings in which nuclear cardiology procedures are helpful to the surgeon in assessment of patients having or being considered for cardiac surgery in the setting of coronary artery disease (CAD). Overall, a risk-benefit approach to MPS results is proposed, with principal focus on identifying patients at risk for major cardiac events who may benefit from a surgical procedure.