The key to survival in patients with acute myocardial infarction is rapid, complete, and durable myocardial reperfusion. The past two decades have witnessed impressive improvements in the ability to provide such treatment via pharmacological thrombolysis or mechanical restoration of flow. As such, a “good problem to have” has evolved: how to choose between two very effective strategies? While there is relatively little argument that small subsets of patients benefit particularly from primary angioplasty (significant contraindications to fibrinolysis, cardiogenic shock), for the vast majority of patients the two treatments offer comparable benefit. Choosing between the two is frequently a moot point for physicians who do not have immediate and continuous access to invasive therapy, but what influences a physician’s decision when both strategies are available remains unclear.

In this issue, Zahn et al attempt to refine our understanding of this decision process by examining the frequency of use of fibrinolysis and primary angioplasty among eight hospitals capable of providing both interventions for patients with acute myocardial infarction eligible for reperfusion treatment.1Of 1532 patients treated at these centres from 1994 to 1997, 641 (∼ 42%) received fibrinolysis and 387 (∼ 25%) underwent primary angioplasty. The rest (∼ 32%) did not receive reperfusion therapy, despite lack of clear contraindications. Overall, in this non-randomised registry cohort, death (8.3%v 13.7%), reinfarction (3.9%v 5.9%), and heart failure (4.9%v 16.4%) occurred substantially less …