Mario Marzilli , MD, PhD
Professor of Cardiovascular Medicine, University of Pisa, Italy
Diabetes and heart failure – a challenging combination
The attention of doctors worldwide is concentrated on the coronavirus infection that has spread quickly all over the globe. The COVID-19 pandemic combines major threats to health and economy, with a dramatic challenge to our daily life. We all feel uncertain about the future, not being sure if and when will we be allowed to go back to our old habits.
In a much more subtle fashion, another “tsunami” is approaching the world of medicine: a major shift in the understanding of myocardial ischemia, still the leading cause of death in industrialized countries. This issue of Heart and Metabolism is focused on this paradigm shift, with a very positive perspective: this “tsunami,” by imposing new diagnostic algorithms, new preventive strategies, and new therapeutic options, will eventually result in a dramatic improvement in the management of myocardial ischemic syndromes.
Dr Boden, whom we all know from his contributions to the area of chronic ischemic syndromes, from the COURAGE trial to the ISCHEMIA trial, stresses that the presence or absence of atherosclerotic coronary artery disease should no longer be considered a surrogate marker for myocardial ischemia and that treating stable angina with percutaneous coronary intervention does not reduce mortality and morbidity, as compared with optimal medical therapy.
Prof De Caterina conveys the concept that coronary atherosclerosis has important adverse prognostic implications and that myocardial ischemia alters prognosis unfavorably on top of coronary atherosclerosis.
Prof Lanza elucidates the fact that the multifactorial nature of myocardial ischemia will demand major revisions in the way we perform and interpret provocative tests.
In my own article, I summarize the evidence that has prompted this paradigm shift, with coronary atherosclerotic obstructions downgraded from being the prominent, if not the sole, mechanism precipitating myocardial ischemia, to just one of the possible mechanisms and certainly not the most common one.
The papers by Dr Orsini and Dr Perera challenge two major dogmas of modern cardiology: the diagnostic value of troponin and the current interpretation of invasive indices of stenosis severity.
The paper by Dr Karwi and Dr Ussher appropriately calls our attention to the “heart” of the ischemic process: perturbations in myocardial energy metabolism.
The clinical case reported on by Dr De Luca and Dr Temporelli nicely shows how the new understanding of chronic ischemic syndromes will modify the clinical management of patients.
Overall, this issue #81 of Heart and Metabolism promises to present a timely and comprehensive opportunity for cardiologists to better understand and manage patients diagnosed as having chronic ischemic syndrome. ■
Disclosure/Acknowledgments: The author has no conflict of interest to declare.