The significant progress that has been made in the treatment of cardiovascular diseases, which are the main cause of mortality, is evidenced by the decrease in the annual number of cardiovascular deaths per 100,000 population from 450 in 1970 to 100 in 2010.

This achievement is largely due to the effective treatment of coronary artery disease, as a result of developments in diagnostic access, pharmacology, cardiac surgery and interventional cardiology and research efforts that have led to the understanding of the mechanisms of morbidity and their targeted treatment.

Coronary artery disease, a consequence of atherosclerotic (obstructive) lesions of the arteries that supply blood to the heart, is the most common cause of cardiac morbidity and mortality. Its most serious manifestation, myocardial infarction, occurs when, after rupture or erosion of an atheromatous plaque and the formation of an occlusive thrombus, the area of ​​the myocardium, supplied by the occluded vessel, burns and undergoes irreversible damage.

The approach to heart attack went through several stages. Until the mid-1960s, long hospital stays and curtailment of activities constituted the limited options strategy.

The creation of the coronary units, with the continuous monitoring of the heart rate and the increased attention to the hemodynamic status of the patient, characterizes the next period and contributes to a noticeable reduction of in-hospital mortality from almost 30% to about 15%, mainly through prevention and timely treatment of catastrophic arrhythmias, but also the optimal, for the time, treatment of the hemodynamic consequences of heart attack.

Since the end of the 1970s, with the use of thrombolytic drugs, which achieve the solution (dissolution) of the occlusive thrombus and the restoration of flow in the artery responsible for the heart attack, the period of myocardial reperfusion begins.

Streptokinase was the first thrombolytic drug to be tested in tens of thousands of patients between 1985 and 1990. A series of new thrombolytic (fibrinolytic) drugs such as t-PA, reteplase, and tenecteplase would follow, proving more effective than streptokinase.

In summary, with thrombolytics the restoration of normal flow (TIMI III flow) is around 55% and in-hospital mortality is reduced to 9%. However, intracerebral hemorrhage is observed in 1% of patients.

The advent of angioplasty in 1978 led definitively, although not without skepticism, to the attempt to open the vessel responsible for infarction in the hemodynamic laboratory (primary angioplasty).

The inevitable comparison of angioplasty with thrombolysis demonstrated the clear superiority of angioplasty in reducing in-hospital mortality (from 9.5% to 7%), recurrent ischemia, and reinfarction. The catalytic effect of the timing of the intervention on the favorable outcome was also documented. If the intervention takes place within the first three hours, the benefit is maximized and of course, the earlier the better. At the same time, it became clear that drug eluting stents offer the best result.

The health systems were organized so that the early recognition of the symptoms of the heart attack leads to the rapid and safe transfer of the patient to a hospital with the possibility of resorting to primary angioplasty and to his promotion without delay to the hemodynamic laboratory.

The time from arrival at the hospital to the opening of the vessel (door to balloon time) was a criterion of organizational adequacy and efficiency of health systems and its shortening is accompanied by a significant effect on in-hospital mortality.

Indicatively, data from the US National Heart Attack Registry (NRMI) show that the reduction in time from 120 to 90 minutes between 1994 and 2006 had a significant contribution to the reduction of in-hospital mortality from 9 to approximately 3%.

The rescue of myocardial tissue is the main goal of reperfusion operations. While the opening of the occluded vessel and the restoration of the flow is possible in a percentage that exceeds 90%, the desired tissue myocardial irrigation is achieved in a percentage of about 65% due to microvascular occlusion from embolism of thrombotic material and accompanying inflammation that prevents the restoration of microcirculation. This delay, with subsequent inadequate myocardial recovery, has significant consequences for future morbidity (mainly heart failure) and mortality.

Finally, the most serious complication of acute myocardial infarction, cardiogenic shock still shows in-hospital mortality of around 40-45%.
Much research is underway to limit myocardial damage. During the acute phase efforts are focused on cardioprotection by mechanical or pharmacological means and restoration of microcirculatory integrity. In the post-infarction period, cell therapies are tested with the aim of regenerating the myocardium.

Rapid myocardial reperfusion with primary angioplasty saves lives. The information and awareness of the population in the early recognition of the symptoms of heart attack and the preparedness of the health systems ensure the optimal result.

Innovative treatments, still being studied and evaluated, are expected to contribute to further reducing the consequences of heart attacks.

The future is bright.