The Year in Cardiology 2018: Acute Coronary Syndromes

Petr Widimsky; Filippo Crea; Ronald K. Binder; Thomas F. Lüscher


Eur Heart J. 2019;40(3):271-282. 

In This Article

Abstract and Introduction


The management of acute coronary syndromes (ACS) is a true success story. Indeed, in 1955 when the then President of the United States Dwight D. Eisenhower had an infarction, the President's personal physician, Dr Howard Snyder, interpreted his symptoms as a gastrointestinal illness.[1] It took 10 h to transfer him to a local hospital where an electrocardiograph had to be brought in from another hospital—a situation that today would be malpractice.[2] The electrocardiogram (ECG) showed an anterolateral acute myocardial infarction (AMI) with ST-segment elevation myocardial infarction or a STEMI as we would call it today based on the recent definition of myocardial infarction (MI).[3] Based on the Fourth Universal Definition of Myocardial Infarction Eisenhower experienced a clear cut Type 1 infarction (Table 1). Today, we distinguish not only five types of infarction, but also myocardial injury, defined by an elevated cardiac troponin (cTn) value, which is also associated with an adverse prognosis. To differentiate myocardial injury from MI, criteria in addition to abnormal biomarkers are required such as ECG changes and evidence of ischaemia.

In the 1950s not many diagnostic tools nor even any effective treatment was available.[4] Not only was an ECG not commonly available, cardiac enzymes were still to be introduced and unavailable at that time. The management of AMI was mainly 'tender loving care', i.e. nitroglycerine and morphine for pain relief. Defibrillation had still to be introduced by Paul M. Zoll a year later.[5] Aspirin (ASA) was labelled as remedy for fever and pain and considered contraindicated for heart patients[6] until Sir John Vane discovered that it inhibits platelet aggregation,[7] Betablockers had still to be developed by Sir James Black, Nobel Prize Laureate in 1988.[8]Finally, Akiro Endo's seminal discovery of statins only occurred in the 1970s[9] and shown to reduce mortality as late as 1992.[10] Lastly, it took another couple years until inhibitors of the P2Y12 receptor became common practice.[11,12] The most important step, proved to be rapid and effective reperfusion and revascularization. Although streptokinase and later tissue plasminogen activators were somewhat successful, it required a bold colleague such as Andreas R. Grüntzig to develop percutaneous coronary intervention (PCI).[13,14] Later, stents (and especially drug eluting stents) improved the results of primary percutaneous coronary angioplasty and made it the first line therapy in patients with ACS.[15,16] As a result of all these impressive developments, mortality of AMI declined stepwise, but eventually dramatically over the past decade[17] (Figure 1). Again this year further steps have been taken to improve the management of patients with ACS as outlined in this review.

Figure 1.

Change in mortality of acute myocardial infarction over time (from Luscher and Obeid17).

The studies included in this review deal initially with pathophysiologic mechanisms, early diagnosis, risk stratification, and outcomes in specific subpopulations, the mid portion reports new data on pharmacotherapy while the last part provides latest data on interventional treatment of ACS.