JAMA 9 May 2007 Vol 297

After myocardial infarction, areas of the myocardium may remain ischaemic without producing any symptoms – this is known as silent ischaemia and is revealed by sophisticated forms of stress imaging. Between 1991 and 1997, well before it became clear that all patients with MI do better with immediate percutaneous intervention (PCI), a group of Swiss hospital randomised their heart attack patients with silent ischaemia to drug treatment or PCI after investigation.The patients who received PCI did better. This SWISSI-II trial should be historical footnote, but given that the UK can only manage a 25% rate of immediate PCI at the time of MI, it may be of some relevance here even now.

Nothing in interventional cardiology stays the same for long. Until a few months ago, we all thought that drug-eluting stents were obviously better than bare-metal stents and doctors began to use them for patients who did not fulfil the trial criteria – so called “off-label