The reperfusion era. Strategies for establishing or maintaining coronary patency

Only 3 decades ago, controversy existed over the origin of the thrombus that occluded coronary arteries during myocardial infarction (MI). Then, the acute clinical angiographic studies of DeWood butterssed new pathological and experimental evidence that the thrombus was the proximate cause of MI and unstable angina. The remaining years of the 20th century saw an explosion of knowledge delineating a spectrum of related disorders now collectively called acute coronary syndromes (ACS). The clinician managing patients is confronted with an array of evidence as more than 75,000 patients worldwide have been randomized to clinical trials in ACS. This article reviews key pathophysiological concepts, presents an initial strategy for triage of patients, and summarizes evidence-based medicine guiding therapy for acute coronary lesions.