The term acute coronary syndrome (ACS) refers to a spectrum of acute severe cardiac disorders which include unstable angina (UA), non-ST segment elevation myocardial infarction (NSTEMI), and ST segment elevation myocardial infarction (STEMI). Patients presenting with ACS represent a major health problem, accounting for 2.5 million hospitalisations and 500 000 deaths annually in the USA alone.¹

We have previously demonstrated that use of combination evidence based medical treatments including antiplatelet agents, β blockers, statins, and angiotensin converting enzyme (ACE) inhibitors is independently and strongly associated with lower six month mortality in patients with ACS.² In the present study we assessed the treatment effect of combination therapy in patients stratified according to their risk of future cardiovascular events according to the thrombolysis in myocardial infarction (TIMI) risk score.

METHODS

There were 1358 patients who were admitted to, or discharged from, inpatient services at the University of Michigan Medical Center from 1 January 1999 to 11 March 2002 with a diagnosis of ACS. Ninety four patients had documented contraindications to β blockers or ACE inhibitors and were excluded from the analysis. The study cohort included the remaining 1264 patients. The study protocol was approved by the institutional review board at the University of Michigan and informed consent was obtained from all patients. Mortality data at six months follow up was obtained for 100% of the patients based on health system record review and/or telephone call interview.

An appropriateness algorithm for the use of each of the various …