Myocardial ischemia in man: current concepts, changing views and future investigation.
Over the past few years the focus of patient management has begun to extend from the mere detection and treatment of chronic coronary atherosclerotic obstructions to the attempt to understand, diagnose and treat the varied mechanisms responsible for acute myocardial ischemia. Management of patients with ischemic episodes is directed to: control of symptoms and/or signs of ischemia; improve prognosis. Several types of effective drugs are available but because of the incomplete knowledge of pathogenesis their use is still largely empirical. When medical therapy fails, surgery and angioplasty can improve coronary flow reserve considerably and even bring it back to normal. In contrast the goal of improving prognosis is more difficult to assess on an individual basis due to the heterogeneity of groups sufficiently large to ensure statistical analysis in long term follow-up and randomised studies. This makes it impossible to apply the average risk of a group to individual patients. For the future, major challenges remain: it will be necessary to learn more not only about the pathogenesis of coronary atherosclerosis but also about the vasomotor control of large and small coronary arteries, the local and systemic factors leading to coronary thrombosis, the myocardial and coronary response to ischemia, and the genesis of ischemic arrhythmias. Finally, since for the majority of coronary patients management is more often concerned with prognosis than with symptoms, we ought to know in more detail the natural history of the various forms of ischemic heart disease: if any given patient is to be allocated with reasonable precision to a prognostic group, the criteria used to categorize patients must be accurate and multiple.
D000787:Angina Pectoris / Q000503:physiopathology / Q000628:therapy; D003326:Coronary Circulation; D003327:Coronary Disease / Q000209:etiology / Q000503:physiopathology* / Q000628:therapy; D003331:Coronary Vessels / Q000503:physiopathology; D006801:Humans; D005082:Physical Exertion; D011379:Prognosis; D014661:Vasoconstriction