The success of fibrinolysis in the treatment of myocardial infarction has been attributed to reperfusion of the occluded vessel, however, it has become clear that it is not just reperfusion but restoration of normal flow—defined angiographically as TIMI-3 flow—in the infarct related artery that dictates mortality. Analysis of the different treatment arms of GUSTO-I,1 the PAMI trials,2 3 and the primary angioplasty registry,4 demonstrates a very clear inverse linear relation between mortality and the rate of TIMI-3 flow achieved in the infarct related artery. The randomised trials of primary angioplasty in acute infarction2 5 6 all point to it being superior to thrombolytic therapy in achieving this goal, although in the GUSTO-IIB substudy7 the benefit was less marked.

The trials of thrombolytic therapy versus placebo all demonstrated a time dependent benefit, the shortest “pain to needle” times having the lowest mortality with a cut off at approximately six hours. This has led to Department of Health guidelines, frantic (albeit appropriate) efforts to keep door to needle times as short as possible, and …