Myocardial infarction: a paradigm of success in modern medicine

Hospital mortality for acute myocardial infarction declined from 30% to 10% in the last 30 years, thanks to coronary care units and early revascularization with thrombolysis, angioplasty, and stent implantation. Pathologists played a major role by establishing plaque rupture and coronary thrombosis as the major cause of acute myocardial infarction and by discovering that ischemic myocardium necrosis progresses from endocardium to epicardium as a "wave front" phenomenon, with potential reversible injury if the reperfusion is accomplished within 3 h. Long-term mortality following myocardial infarction is mostly due to sudden electrical death, which may be prevented by pharmacologic (antiarrhythmic drugs) and nonpharmacologic (implantable cardioverter defibrillator, pacemaker) therapy. Ventricular assist devices may support the left ventricle as a bridge to transplantation. Long-term mortality at distance from acute myocardial infarction declined from 10% to 2% per year. Despite these indisputable achievements, there are still pending questions: in vivo identification of vulnerable plaque, mechanisms of thrombosis by plaque erosion, prompt treatment on the spot of instantaneous cardiac arrest by external defibrillation, adverse effect of myocardial reperfusion, fate of bare- and drug-eluting coronary stents. With these limitations and challenges well in mind, nowadays myocardial infarction does not represent a nightmare as it was in the past. The achievements in its prevention, diagnosis, and treatment should be considered as a pride of cardiovascular medicine.