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Myocardial ischaemia 

Myocardial ischaemia
Myocardial ischaemia

Dr Kalpa De Silva

and Dr Divaka Perera

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date: 25 July 2021

The fields of coronary physiology and interventional practice have evolved remarkably over the last forty years. Specifically in relation to the improved understanding of basic pathophysiological principles underpinning myocardial ischaemia and infarction, and also in the expansion of in vivo human research, allowing novel insights and increased understanding into the functioning of the coronary circulation. This period has, arguably, witnessed the most successful era of cardiovascular research; with effective translation seen in improvements in clinical practice disease, with particular relevance to the treatment of coronary artery disease.

The widespread implementation of cardiac catheterization has been a key development in the assessment and treatment of coronary artery disease. Whilst this has been the gold-standard diagnostic test for coronary disease in both the chronic and acute settings during this period, it has also provided a platform for a new generation of research to be undertaken, which has broadened myocardial ischaemia research from the initial building blocks of cellular and molecular biology investigation to dynamic invasive coronary physiology, paralleled by the advent of unique clinical applications, such as pressure wire assessment of coronary stenoses.

Advancement in technology and methodological techniques has allowed more detailed investigation of the pathophysiological mechanisms at the root of myocardial ischaemia, which in turn has led to improved understanding of the phenomenon of ischaemia and subsequent development of various treatment and management strategies. A small proportion of the key breakthroughs of the last four decades are described in the chosen papers that follow.

Selecting ten ‘landmark’ papers in the field of myocardial ischaemia has been an extremely challenging task, as the topic encompasses many aspects of cardiovascular medicine, cross-cutting between themes, including basic science, interventional cardiology, and imaging sciences. The choice of papers considered to be suitable for review in this chapter were vast, and inevitably there are studies that have provided cutting edge research and moved the specialty forward, that have not been included. The papers finally chosen for inclusion encompass a range of topics, including the molecular basis of ischaemia and infarction, the discovery and potential clinical utility of myocardial pre- and post-conditioning, assessment, and prognostic value of myocardial viability, to recent large contemporary randomized controlled trials such as Fractional flow reserve versus Angiography for Multivessel Evaluation (FAME). Additionally, prominent literature review articles that were seminal in focusing, developing, and challenging the understanding of myocardial ischaemia and infarction are also included. The studies and articles outlined in the chapter, aim to provide a thread through the progressive advancement seen in the field, from the molecular understanding of ischaemia to the application of clinical tools in current practice. Whilst this entails a wide breadth of coverage, relevance and applicability to the practising cardiologist is maintained throughout.

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