Improved prognosis during and after myocardial infarction: a plea for an integrated and stratified approach.

Immediately after the first signs and symptoms of acute myocardial infarction are detected, its prognosis is determined by the size of the area at risk, the availability of collaterals and the time at which interventions are carried out. Preservation of as much myocardial tissue as possible is the key issue. Relief of obstruction of the thrombosed nutrient artery and reperfusion of the myocardium in jeopardy within 4 hours after onset of symptoms can lead to limitation of the ultimate infarct size, maintained ventricular function and a marked reduction of the first year mortality. Early supportive therapy with beta-blockade and calcium antagonists may enhance this effect. Recent data published on 533 patients randomized to either a reperfusion strategy or to conventional therapy, combined with those from the recent literature on thrombolysis and early beta blockade, provide the basis for this point of view. Once infarction is unavoidable and in the process of consolidation, supportive therapy is recommended. This still can change the outcome by timely correction of electrical instability, normalization of afterload and heart-rate, and the avoidance of secondary complications such as peripheral thrombosis. To determine the best course after recovery from the infarction, a symptom limited bicycle stress test, radionuclide ventriculography and 24 hour ambulatory electrocardiogram at the time of discharge were compared in predicting one year survival in 351 hospital survivors. A history of previous myocardial infarction or of heart failure during the current episode proved to be the strongest clinical predictor of early death.(ABSTRACT TRUNCATED AT 250 WORDS)