Pathophysiologic bases for adjunctive therapies in the treatment and secondary prevention of acute myocardial infarction

Recent Advances in Pharmacological and Non-Pharmacological Strategies of Cardioprotection

Ischemic heart diseases (IHD) are the leading cause of death worldwide. Although the principal form of treatment of IHD is myocardial reperfusion, the recovery of coronary blood flow after ischemia can cause severe and fatal cardiac dysfunctions, mainly due to the abrupt entry of oxygen and ionic deregulation in cardiac cells. The ability of these cells to protect themselves against injury including ischemia and reperfusion (I/R), has been termed “cardioprotection”. This protective response can be stimulated by pharmacological agents (adenosine, catecholamines and others) and non-pharmacological procedures (conditioning, hypoxia and others). Several intracellular signaling pathways mediated by chemical messengers (enzymes, protein kinases, transcription factors and others) and cytoplasmic organelles (mitochondria, sarcoplasmic reticulum, nucleus and sarcolemma) are involved in cardioprotective responses. Therefore, advancement in understanding the cellular and molecular mechanisms involved in the cardioprotective response can lead to the development of new pharmacological and non-pharmacological strategies for cardioprotection, thus contributing to increasing the efficacy of IHD treatment. In this work, we analyze the recent advances in pharmacological and non-pharmacological strategies of cardioprotection.

SSM Health Care clinical collaboratives: improving the value of patient care in a health care system

BACKGROUND

In 1998 SSM Health Care (St Louis) began a series of clinical collaboratives modeled after The Institute of Healthcare Improvement (Boston) Breakthrough Series. There are now four collaboratives, with 46 teams in progress, and four additional collaboratives are scheduled.

COLLABORATIVE TOPICS AND STRUCTURE

Each collaborative consists of three phases: the prework, active, and the continuous improvement phases. The structure of the collaboratives is quite similar to that of the Institute for Healthcare Improvement Breakthrough Series. However, the SSMHC collaboratives include a continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. RESULTS OF COLLABORATIVES IN PROGRESS: Entity teams participating in multiple collaboratives seem to ascend a learning curve and become progressively more skilled in subsequent collaborative work. In Collaborative 1--Improving the Secondary Prevention of Ischemic Heart Disease--the participating entities showed significant improvement in cholesterol screening and treatment. In Collaborative 2--Improving Prescribing Practices--the collaborative teams also showed significant improvement, with a combined cost savings of approximately $450,000 per year. Collaboratives 3--Using Patient Information to Improve Care and Assure Success-and-4--Enhancing Patient Safety Through Safe Systems--are under way.

SUMMARY

The collaboratives accelerate improvement work through sharing of successes and failures and peer influence within a reinforcing environment. Most of the collaborative teams have reached their project goals, and the pace of clinical improvement work has accelerated since the start of the collaboratives. The collaboratives provide an environment for clinicians to constructively participate in improvement of patient care.

Thrombosis and coagulation abnormalities in the acute coronary syndromes

The acute coronary syndromes, that include unstable angina, acute myocardial infarction, and many cases of sudden cardiac death, exact a considerable price on society in terms of mortality, morbidity, and health care costs. The coronary atherosclerotic lesion is often an indolent and progressive entity that can destabilize causing an acute syndrome with or without warning. The majority of acute coronary syndromes result from events such as rupture or disruption of the atherosclerotic plaque with intracoronary thrombosis and ischemia of the distal myocardium as a result. Advances in our understanding of the process underlying the acute coronary syndromes has allowed for the identification of targets and rational therapeutic strategies for the prevention and treatment of these syndromes. Many of these therapeutic strategies involve the reversal of prethrombotic forces that often coexist with coronary atherosclerosis. Even with recent advances in our approach to atherosclerosis, intracoronary thrombosis, and the resulting acute coronary syndromes, an unacceptably high event rate persists after these syndromes. Further advances in the prevention and treatment of coronary atherosclerosis and its thrombotic complications depends on a more thorough understanding of the biology of the atherosclerotic plaque and the factors which influence its stability.

Emergency management of acute myocardial infarction. Focus on pharmacologic therapy

Treatment of acute myocardial infarction has evolved significantly in the past two decades. Reperfusion therapies of thrombolysis and percutaneous angioplasty are major advances that can be employed to save infarcting myocardium and reduce mortality. When reperfusion therapy is combined with the use of aspirin, beta-blockade, heparin, and nitroglycerin, the emergency management of the patient with myocardial infarction can be completed. Outcomes in patients are determined by what happens in the first few minutes to hours after onset, and any delay in diagnosis or treatment may have significant consequences. This article reviews intervention and treatment strategies for acute myocardial infarction.