In-hospital fatality from acute myocardial infarction remains high. Precisely how high depends on the way data are collected, and on what patients are included. While clinical trials of thrombolysis suggest that the case fatality rate should be around 7%, registry data suggest that the true “real world” rate (which includes many elderly patients) is much more like 20%. Gitt and Senges1 argue that the high death rate results from failure to use thrombolysis, and that as it will be difficult to improve on current thrombolysis rates the way forward is to increase the use of immediate, or primary, angioplasty. If this strategy is correct, the implications for the National Health Service are enormous. There is evidence that hospitals with a higher volume of angioplasty procedures show a lower fatality rate among patients undergoing primary angioplasty, and the American College of Cardiology/American Heart Association (ACC/AHA) guidelines2 suggest that primary angioplasty should be considered as an alternative to thrombolysis “if performed in a timely fashion (balloon inflation within 90 minutes of admission) by individuals skilled in the procedure (more than 75 procedures per year) and supported by experienced personnel in a laboratory environment (centres performing more than 200 angioplasty procedures per year) that have cardiac surgical capabilities”. Before such facilities are made widely available in the UK we need to think very hard. We must not fall into the trap of assuming that because an “old” treatment is not producing the results we would like, the “new” one will be better.

The theoretical advantages of primary thrombolysis are clear. …