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ST-segment elevation myocardial infarction: the new ESC Guidelines.

ST-segment elevation myocardial infarction or STEMI continues to be one of the most dangerous acute complications of coronary artery disease. Although huge progress has been made in its management in the last decades, in-hospital mortality is still in the range of 5–8%. To allow for further optimization of the management of STEMI, considering also the most recent evidence, a task force of the ESC published updated guidelines. This Focus Issue on STEMI contains the updated ‘2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)’. Nowadays, patients with STEMI undergo rapid revascularization, most commonly with primary percutaneous coronary intervention. Although these procedures allow for immediate relief of ischaemia and pain associated with it, reperfusion injury is thought to represent another insult to the ischaemic pre-conditioning myocardium. Many drugs and antibodies, as well as have been tested in an attempt to reduce reperfusion injury with commonly little effect. In their Brief Communication entitled ‘A single-chain antibody–CD39 fusion protein targeting activated platelets protects from cardiac ischaemia/reperfusion injury’, Karlheinz Peter and colleagues from the Baker Heart Research Institute in Melbourne, Australia report on the therapeutic potential of CD39, a cell membrane NTPase with anti-inflammatory and antiplatelet effects. In a quest to avoid haemostatic problems, they designed a fusion protein consisting of the extracellular domain of CD39 and a single-chain antibody (Targ–CD39) that specifically binds to activated glycoprotein (GP)IIb/IIIa and thus only to activated platelets. Using an ischeamia/reperfusion mouse model, they achieved remarkable protection of the reperfused tissue with Targ–CD39 compared with control. Targ–CD39 restored the ejection fraction and fractional shortening to a level indistinguishable from pre-injury status, while controls showed functional deterioration. Employing advanced, clinically relevant methods of ultrasound analysis, they observed that both radial and longitudinal strain and strain rate showed infarct-typical changes of myocardial deformation in controls, but not in Targ–CD39-treated mice. Histological assessment confirmed strong reduction of infarct size and an increase in neovascularization. Thus, again, at least experimentally, Targ–CD39 holds promise for treatment of myocardial infarction. The translational value of these findings is put into context in an Editorial by Meinrad Gawaz from the University Hospital Tübingen in Germany. While plaque rupture or erosion with concomitant platelet activation is the most common cause of acute coronary syndromes, functional alterations of epicardial coronary arteries (i.e. vasospasm) or of the coronary microcirculation may be the underlying cause of myocardial infarction in patients with non-obstructive coronary arteries, i.e. in MINOCA and in Tako Tsubo syndrome. In a clinical research manuscript entitled ‘Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests’, Giampaolo Niccoli and colleagues from the Catholic University of the Sacred Heart in Rome, Italy evaluated the prognostic value of intracoronary provocative tests in patients presenting with MINOCA. Immediately after coronary angiography, an invasive provocative test using acetylcholine or ergonovine was performed in 80 consecutive patients. Provocative tests were positive in 46% due to epicardial spasm in 66% and due to microvascular spasm in 35%. After a median follow-up of 36.0 months, patients with a positive test had a significantly higher occurrence of death from any cause and readmission for acute coronary syndromes, as well as a worse angina status as compared with patients with a negative test (Figure 1). Thus, in patients presenting with myocardial infarction and non-obstructive coronary arteries, a positive provocative test for spasm is safe and identifies a high-risk subset of patients. These important findings are further discussed in an Editorial by Juan C. Kaski from St George’s at the University of London. In a further clinical research article entitled ‘Long-term survival and causes of death in patients with ST-elevation acute coronary syndrome without obstructive coronary artery disease’, Hedvig Bille Andersson and colleagues from the Rigshospitalet in Copenhagen, Denmark aimed to study survival and causes of death in 4793 consecutive patients with ST-elevation acute coronary