F ully developed acute myocardial infarction was recognized at autopsy throughout the 19th and 20th century. Furthermore, many clinicians (eg, Osler) were excellent pathologists and often observed acute and healed myocardial infarcts (MI) in their patients after death. However, more often than not, the acute infarcts they observed did not show a thrombus in the coronary artery supplying the infarcted region of the heart. As a result, although the infarct was usually supplied by a particular coronary artery in the myocardium and the heart usually exhibited severe atherosclerotic coronary artery disease, there was enough variation from patient to patient so that the clinicians of this day were reluctant to attribute the myocardial necrosis to interruption of the blood supply.1 However, by 1880, several German experimentalists 2 had occluded major coronary arteries in the canine heart and found easily identifiable acute MI 24 hours later. However, these data failed to convince most of the experimentalists and the clinicians that human infarcts were caused by an interruption in coronary blood flow. Abstract: A selective history of the pathophysiological, structural, and metabolic changes found during an episode of severe myocardial ischemia in the canine heart is presented. The changes that cause ischemic injury to become irreversible are discussed in detail because these changes are the target of any successful therapy designed to prevent ischemic cell death. Of these, the disruption of the sarcolemma, an injury the development of which is accelerated in vivo by the contraction of viable tissue elsewhere in the heart traumatizing the ischemic area, plus the changes in high-energy phosphate and the total adenine nucleotide pool are considered to be the critical events leading to the development of irreversibility. The discovery of preconditioning with ischemia is discussed, together with a brief description of postconditioning. Finally, reperfusion injury is discussed in a summary fashion. The evidence for the fact that myocytes are salvaged by reperfusion is presented, as is the evidence that myocytes become unsalvageable by reperfusion as the duration of ischemia increases. The concept that some of the myocytes that die after successful reperfusion with arterial blood actually are killed by changes initiated by reperfusion, so-called lethal reperfusion injury, is attractive in that prevention of this change would lead to greater salvage; however, the prevalence of this phenomenon in clinical practice remains to be determined. of the thrombus restored arterial flow and reversed many of the clinical and electrocardiographic signs of on-going infarction. It seems likely that the explanation for the failure of the early workers to find a thrombus in hearts with a welldeveloped acute infarct was because of the action of endothelial fibrinolysins in the adjacent endothelium dissolving the thrombus that had caused the MI. Hence, although a coronary artery had to be obstructed to cause infarction, clots were observed irre...