The concepts of acute coronary care are changing so rapidly that it is appropriate that the volume ACUTE CORONARY CARE: PRINCIPLES AND PRACTICE, published early in 1985, would have yearly updates. The process of rapid production of camera-ready manuscripts has added new capability to the exchange of information. ACUTE CORONARY CARE 1986 is the first of a series of yearly updates in this important area of cardiology. Materials published during the fall of 1984, including abstracts for the November American Heart Association meetings were reviewed by the editors to identify the areas of new information and the authors making important contri butions. Manuscripts were completed and edited during the spring of 1985 and the final camera-ready versions were delivered to Martinus Nijhoff by mid-July. The broad area of coronary care is divided into its five time sectors: Pre-hospital, Post-admission, Coronary Care Unit, Pre-discharge, and Conva lescent. As patients are more frequently encountered in the pre-hospital phase, it has become evident that alterations in the autonomic nervous system have a great impact on the clinical situation. The chapter by Ron Victor emphasizes the important interactions between the nervous system and the cardiovascular system in this critical situation."

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.

When a patient develops symptoms suggestive of and infarction, this section is emphasized. There acute coronary insufficiency, the health care sys- are brief sections on prediction and prevention of tem is presented with a challenging diagnostic ischemic events, methods of diagnosing and siz- and management problem. During the past 20 ing infarcts, and methods of monitoring the pa- years, hospitals have been developing coronary tient with myocardial ischemia. A major focus of care units as the specialized inhospital facilities for the text is on "coronary care. " As indicated above, such patients. For the past 15 years, many com- during the past 20 years five distinct phases of munities have employed paramedical personnel coronary care have evolved: (a) prehospital, (b) to extend the principles of "coronary care" to the postadmission, (c) coronary care unit, (d) predis- site of the patient who develops the problem. charge, and (e) convalescent. Cardiac rehabilitation programs have also been The section on pathophysiology begins with a established to facilitate the return to function of chapter by Greenfield and Rembert discussing patients who have had acute coronary insuffi- the factors that determine the transmural distri- ciency. More recently, aggressive medical and bution of blood flow. Reimer then shows the surgical techniques have been developed to either relationship between coronary blood flow and prevent or limit the extent of myocardial necrosis both reversible and irreversible damage to the that develops due to acute coronary insufficiency. myocardium.

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.

The concepts of acute coronary care are changing so rapidly that it is appropriate that the volume ACUTE CORONARY CARE: PRINCIPLES AND PRACTICE, published early in 1985, would have yearly updates. The process of rapid production of camera-ready manuscripts has added new capability to the exchange of information. ACUTE CORONARY CARE 1986 is the first of a series of yearly updates in this important area of cardiology. Materials published during the fall of 1984, including abstracts for the November American Heart Association meetings were reviewed by the editors to identify the areas of new information and the authors making important contri butions. Manuscripts were completed and edited during the spring of 1985 and the final camera-ready versions were delivered to Martinus Nijhoff by mid-July. The broad area of coronary care is divided into its five time sectors: Pre-hospital, Post-admission, Coronary Care Unit, Pre-discharge, and Conva lescent. As patients are more frequently encountered in the pre-hospital phase, it has become evident that alterations in the autonomic nervous system have a great impact on the clinical situation. The chapter by Ron Victor emphasizes the important interactions between the nervous system and the cardiovascular system in this critical situation."