During the 25 years since acute coronary care was focused into
Coronary Care Units there have been three major Phases: I.
prevention of death caused by arrhythmias; II. prevention of death
due to myocardial failure; and III. limitation of infarct size. In
the latter two Phases, there has been infringement upon the time
honored concept of a prolonged period of rest for the patient in
general and the heart in particular to minimize myocardial
metabolic demands. During the second Phase of coronary care,
patients with myocardial failure received aggressive measures to
increase cardiac work via increase in preload, decrease in
afterload, and direct increase in inotropy. It was believed that
true cardiogenic shock was so irreversible that it should be
prevented by vigorous efforts to improve the cardiac output despite
the risk of extending the area of ischemic myocardium. However,
Phase II produced minimal overall reduction in mortality. In the
initial part of Phase III, myocardial infarct (MI) size limitation
was attempted by reducing myocardial metabolic demands via either
beta adrenergic or calcium channel blocking agents. We are
currently several years into the second part of Phase III of
coronary care where the principle means of limiting MI size is
restoration of coronary blood flow.
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