Advances in clinical management of acute myocardial infarction in the past 25 years.

The management of acute myocardial infarction in the past 25 years has emerged from a state of masterful inactivity to one of intensive care based on a new discipline of aggressive management. This has increased the chances of survival of the victim of infarction and could well be one of the major reasons for the decline in mortality due to coronary heart disease in the United States since 1968. Because resuscitative techniques must be instituted within 4 minutes after the onset of cardiac arrest, the attendant nurse had to learn the new emergency lifesaving techniques and assume a crucial role as a physician's assistant. The various stages in the evolution of coronary care discipline began with cardiopulmonary resuscitation and were followed by pacemaker application, arrhythmia prophylaxis and insertion of pulmonary venous flow-directed catheters and arterial lines that permit monitoring and control of ventricular filling pressures. Other developments in better management of the failing heart have included methods to salvage jeopardized myocardium, strategies for the prevention of sudden death, the application of revascularization techniques after acute coronary occlusion and new noninvasive computerized technology to provide enhanced contrast images of cardiac perfusion that can be directly integrated with measurement of function.