Clinical Management of Myocardial Infarction

Despite notable advancements in the acute and long-term management, coronary artery disease and myocardial infarction (MI) remain the leading cause of mortality worldwide. Atherothrombosis overlying coronary plaque rupture or erosion is the main pathophysiological mechanism of MI. Plaque disruption leads to the exposure of tissue factors and subintimal components to the luminal blood, triggering activation of the coagulation cascade and platelet aggregation, which ultimately result in luminal thrombosis. Protocolization of timely and effective revascularization in patients with acute MI is a milestone in the history of cardiovascular medicine. In the last decades, the widespread implementation of systems of care aimed at prioritizing immediate reperfusion by primary percutaneous coronary intervention or fibrinolysis (if primary percutaneous coronary intervention cannot be performed within 120 minutes), advancements in the acute phase management and secondary prevention measures has led to a substantial reduction of morbidity and mortality of MI. However, coronary artery disease and MI remains responsible for >370 000 deaths in the United States each year, and a nonnegligible proportion of patients with MI still experience recurrent cardiovascular events despite effective control of conventional risk factors. These considerations prompted the pursuit of adjunctive pharmacological agents aimed at facilitating reperfusion of the infarct-related artery and optimized secondary prevention measures to mitigate post-MI complications and residual risk for recurrent MI. This state-of-the-art review summarizes the contemporary clinical management of MI, focusing on diagnostic framework, approach to risk stratification, and treatment. A critical appraisal of the existing evidence on revascularization strategies (including timing and guidance of complete revascularization) and emerging pharmacological treatment approaches for secondary prevention of MI are also provided, with a special emphasis on the increasingly recognized entity characterized by MI without obstructive coronary artery disease. Further efforts are needed to refine risk prediction and diagnostic algorithms for occlusive MI, reduce delays to reperfusion, improve upon cardiogenic shock-related mortality, and ultimately advance adoption of secondary prevention measures that will further enhance patient outcomes.