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(Circulation. 2009;119:1293-1303.)
© 2009 American Heart Association, Inc.

Controversies in Cardiovascular Medicine

Is duration of symptoms the key modulator of the choice of reperfusion for ST-elevation myocardial infarction?

Duration of Symptoms Is the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

Paul W. Armstrong, MD; Cynthia M. Westerhout, PhD; Robert C. Welsh, MD

From the University of Alberta, Edmonton, Alberta, Canada.

Correspondence to Paul W. Armstrong, MD, Department of Medicine, Division of Cardiology, University of Alberta, 2-51 Medical Sciences Bldg, Edmonton, Alberta T6G 2H7, Canada. E-mail paul.armstrong@ualberta.ca

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 

Time has been transformed, and we have changed; it has advanced and set us in motion; it has unveiled its face, inspiring us with bewilderment and exhilaration.

—Kahlil Gibran¹

The intense focus at the nexus between elapsed time and outcomes in patients with ST-elevation myocardial infarction (STEMI) signals its far-reaching implications for public health and the healthcare system. In this perspective, we demonstrate not only the time dependence of the 2 principal forms of reperfusion therapy but also how the efficacy of each depends on the baseline risk of the individual in whom it occurs, as well as where the event unfolds in time, space, and context. These variables play a crucial role in determining the choice of best therapy, thereby confirming the admonition that 1 size does not, and could not, fit all individuals in all circumstances at all times.^2–4 A central issue that bears on the interpretation of the reperfusion literature is which of the various definitions of time is used. We will use the terminology summarized in Table 1 and explore opportunities to modulate the delay incumbent with STEMI treatment.

View this table:   Table 1. Time Definitions and Clinical Reperfusion

Response by Bogaty p 1303

	Pathobiology of Myocardial Infarction and Time

 
An ironic divide exists between the precision of time-dependent laboratory observations on the extent of myocardial injury and the frustrating imprecision of this metric when applied to humans. The notion of reversible ischemic cell damage after coronary occlusion was framed more than half a century ago.⁵ Subsequent canine experiments demonstrated that ischemic necrosis begins . . . [Full Text of this Article]

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