Treatment of a patient with acute myocardial infarction (MI) has become easy, at least in the case of the 55-year-old previously healthy 85 kg man with 4 mm ST-segment elevation in the precordial leads and typical chest pain since 1 h in whom the entire set of laboratory parameters is normal except for evidence of dyslipidaemia. In this patient, results from well-conducted randomised clinical trials precisely inform us which interventions to apply to optimise the clinical outcome.1 However, in an analysis from the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry published in Heart, Radovanovic et al2 show that in the real world it is not as simple as that. The AMIS Plus registry included nearly 30 000 patients admitted with acute coronary syndrome (ACS; acute MI as well as unstable angina) to 106 Swiss hospitals during a 10-year period. Nearly 50% of patients had one or more comorbidities, and comorbidities had an important impact on in-hospital outcomes as well as 1-year outcomes. There was a dose–effect relationship between the burden of comorbidities as quantified by the Charlson Comorbidity Index (CCI) and in-hospital mortality: the OR adjusted for other baseline characteristics and treatment for in-hospital mortality for patients with comorbidities weighted with one (CCI=1), two (CCI=2) or three or more (CCI≥3) points compared with those without any comorbidities (CCI=0) were 1.36, 1.65 and 2.20. When looking at single comorbidities, the strongest predictors of in-hospital mortality were heart failure, metastatic tumours, renal disease and diabetes. In a sizeable subgroup of 7066 patients with a median follow-up of 386 days after the event the age-adjusted OR for mortality was 1.44 per CCI point.

This article is an important contribution to the literature for a number of reasons. First, this is the so far largest and most comprehensive data set on the prognostic role of …