JAMA 14 Feb 2007

In less than ten years, the treatment of myocardial infarction has progressed from just giving aspirin and ensuring the quick delivery of thrombolysis, to complex strategies to maximise early invasive therapy together with the use of glycogen IIb/IIIa inhibitors. I have tried to tell you about every twist and turn on the way, all the time hoping that someone might come up with a snappier name for these drugs and simpler treatment algorithms for acute coronary syndromes – ones that I might actually be able to remember. Fortunately I don’t have to: but if any of you guys are at the sharp end, be informed by the ACUITY trial that it may be better to give Gp IIb/IIIa inhibitors early rather than immediately before a percutaneous intervention. Although the trial involved 450 different institutions around the world, it didn’t quite achieve statistical significance.

603 Historically, bloodletting has probably killed more patients than any other medical treatment, though it may have saved the odd one with haemochromatosis and heart failure. There is a school of thought that still favours bleeding to reduce iron storage in peripheral vascular disease, and they may have a point. Regular bleeding to reduce iron stores and achieve pre-set levels of ferritin and haemoglobin showed a trend towards improved cardiovascular outcome and survival in patients with PVD, but again not sufficient to achieve significance.

Maleness is a cardiovascular risk factor: add one or two more factors, and you know that a chap over 55 will be better off with at least a couple of protective drugs (for statins, see the latest issue of Bandolier). But it’s less straightforward on the distaff side, as this paper illustrates. The Reynolds Risk Score was derived from a cohort of nearly 25 000 women over 45 followed up for a little over 10 years. This is a very sophisticated score indeed, which initially factored in 35 variables, and sometimes their natural logarithms, and then worked down to the most useful possible 8 (still including some natural log values). The new one is high sensitivity C-reactive protein. Even if you ever get access to this measurement, you will need much more than the back of an envelope to derive this score, which is named after the rich gent who set up the foundation which funded the study. Thanks to his largesse, you can bung the factors into www.reynoldsriskscore.com