Direct angioplasty for acute myocardial infarction is either an unnecessary luxury or the greatest thing since sliced bread, depending on your persuasion.1 It has been argued by proponents of thrombolysis that it is impractical to consider angioplasty in most instances because the majority of patients with acute infarction present to hospitals without the facilities to perform it. In this edition of Heart, Zijlstra et al challenge this premise.2 They compared the outcome of 104 patients with acute infarction referred for direct angioplasty from peripheral hospitals, with 416 patients who presented to the tertiary institution. Despite the fact that the patients transferred were generally of higher risk, they did just as well as those who presented directly. Importantly, the overall ischaemic time was similar in both groups. Careful organisation meant that the time lost in transportation was made up by avoiding delays in vacating catheter laboratories.

There are obvious limitations to the study that the authors acknowledge. Essentially it was a non-randomised, retrospective audit, conducted in a demographically compact part of the Netherlands. For more than 90% of patients, the distance between the hospitals was less than 50 km. Restoration of coronary flow was achieved in 78% of the transferred group …