*4.1.3 Metabolic control*

The metabolic modulation of the insulin glucose axis by infusion of glucoseinsulin-potassium was evaluated in different trials with diverse and contradictory results that when taken together result in an intervention without net benefit compared to placebo. However, these guidelines suggest that it could be of benefit in patients with less than 12 hours of evolution, in Killip Kimball. Beyond that, the guidelines do not establish an indication with a level of evidence defined for this intervention [58].

### *4.1.4 Glycemia control*

During AMI, the levels of catecholamines and cortisol increase, insulin decreases, and blood glucagon increase. This leads to a notable increase in blood glucose and decreased glucose utilization by cells. Free fatty acids and their metabolites are increased that increase myocardial damage by different mechanisms (direct inhibition of glucose oxidation, increased demand for O2, direct toxicity). Insulin can reverse some of these mechanisms by inducing the production of ATP from aerobic glucose metabolism in the myocyte. Several studies mentioned in these guidelines demonstrated benefits in patients with hyperglycemia who received insulin infusion for strict glycemic control during the event. These guidelines establish that the normalization of insulin glycemia is a class I indication with a level of evidence B for patients with complicated AMI and class IIa with a level of evidence B for patients with uncomplicated AMI [59–61, 62].

#### **4.2 ESC guides 2017**

These guidelines mention, scarcely, that to reduce myocardial damage beyond reperfusion therapy, some strategies that include pharmacological and mechanical therapies have been demonstrating the potential to reduce the size of AMI by decreasing the impact of reperfusion injury in small clinical trials. But there is no large-scale clinical study that has demonstrated clinical benefit. Therefore, they make no recommendation regarding measures to limit reperfusion injury or any other therapy to reduce myocardial damage during the event, beyond reperfusion [63].

### **5. Current reperfusion adjuvant therapy status**

The use of B blockers and nitrates is favorable to reduce myocardial damage caused by primary and secondary ischemia, reducing the imbalance between supply and demand of O2 and nutrients until reperfusion. Beside, these drugs are useful to optimize the conditions of pre- and post-loading of LV, decrease heart rate and blood pressure, and thus limit the damage caused by mechanical stress. A wide variety of potent platelet antiplatelets such as clopidogrel, prasugrel, or ticagrelor added to the routine use of aspirin were shown to reduce the recurrence of ischemic events after reperfusion (secondary ischemia). Although it is not clearly established by evidence from clinical trials, thromboaspiration; potent vasodilators at the microvasculature level such as adenosine and calcium blockers, among others; and the use of IIb–IIIa glycoprotein inhibitors may be effective in prevention and treatment of no-reflow. The phenomenon of no-reflow can cause ischemia (secondary ischemia) to continue beyond the recanalization of the epicardial artery. However, reperfusion inflammation and injury are not prevented or treated in daily practice.

#### **6. Perspectives**

The development of reperfusion therapies for AMI was shown to reduce mortality strongly. There are possibilities to optimize its use. Health teams must continue fighting to shorten the system times and detect the best strategy according to the context in which they operate. There are working groups that carry out research in basic sciences, translational research, and clinical research and are making advances in myocardial protection. Cyclosporine and colchicine are currently evaluated for their ability to reduce the damage caused by inflammation. Developed treatments

**251**

**Author details**

MEDIS Institute, Salta, Argentina

provided the original work is properly cited.

Miguel Angel Farah\*, Franco Farah and Miguel Alejandro Farah

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: farahale@yahoo.com

*Primary Angioplasty: From the Artery to the Myocardium*

for *continuing myocardial protection* [52], which the clinical cardiologists administer from the moment of diagnosis until the convalescence of the patient in a critical unit, could potentially preserve myocardium during the delay of the system and the early evolution of the event. Developed *controlled reperfusion* [52] procedures where the interventional cardiologist assumes the treatment not only of the guilty vessel but also of the myocardium could potentially decrease myocardial damage, preserve ventricular function, and improve the prognosis of patients suffering from AMI. The concept of *controlled reperfusion* involves deciding how to reperfuse (e.g., post-conditioning) and with what to reperfuse (e.g., administering to the ischemic myocardium, through dedicated catheters, before the opening of the artery, blood modified or enriched with drugs), preparing the myocardium for a more complete

A wide field of research appears to improve the treatment outcome of patients suffering from AMI aiming not only at arterial recanalization but also at myocardial

*DOI: http://dx.doi.org/10.5772/intechopen.91832*

AMI acute myocardial infarction

ECG electrocardiogram ROS reactive oxygen species ADA anterior descending artery

and definitive recovery.

preservation.

**Abbreviations**

*Primary Angioplasty: From the Artery to the Myocardium DOI: http://dx.doi.org/10.5772/intechopen.91832*

for *continuing myocardial protection* [52], which the clinical cardiologists administer from the moment of diagnosis until the convalescence of the patient in a critical unit, could potentially preserve myocardium during the delay of the system and the early evolution of the event. Developed *controlled reperfusion* [52] procedures where the interventional cardiologist assumes the treatment not only of the guilty vessel but also of the myocardium could potentially decrease myocardial damage, preserve ventricular function, and improve the prognosis of patients suffering from AMI. The concept of *controlled reperfusion* involves deciding how to reperfuse (e.g., post-conditioning) and with what to reperfuse (e.g., administering to the ischemic myocardium, through dedicated catheters, before the opening of the artery, blood modified or enriched with drugs), preparing the myocardium for a more complete and definitive recovery.

A wide field of research appears to improve the treatment outcome of patients suffering from AMI aiming not only at arterial recanalization but also at myocardial preservation.
