• Acute coronary syndrome

The Authors' reply: We thank Drs Mamas and Fraser for their interest1 in our recent editorial in Heart on NICE guidance for the investigation of chest pain.2

Please can we point out that our editorial referred specifically to the NICE guidance on chest pain (clinical guidance 95).3 The letter from Mamas and Fraser refers to the separate NICE guidance on unstable angina and non-ST elevation myocardial infarction (MI) (clinical guidance 94).4 Nevertheless, as an author (KAAF) of the GRACE risk score5 and an author (KAAF) of the 5-year outcome meta-analysis of interventional trials in non-ST elevation acute coronary syndrome (ACS),6 we are pleased to respond to the letter.

First, the guidance specifically states the recommendation to ‘use risk assessment to guide clinical management, and balance the benefit of a treatment against any risk of related adverse events in the light of this assessment’. Therefore, we agree that such risk assessment should be used in the context of the risks and benefits of the specific patient and there may be particular reasons why a patient is at higher risk of thrombotic events and higher risk of future MI.

Second, please can we point out that although the NICE guidance chose to simplify risk scoring by only quoting the risk score for mortality, the GRACE programme developed risk prediction for both death and myocardial infarction (http://www.outcomes.org/grace).5 Furthermore, in our publications we describe the fact that the risk-scoring algorithms are less accurate at predicting recurrent MI than predicting death.5

Our recent manuscript describing the 5-year outcome of interventional strategies in non-ST elevation ACS also highlights the point made by Mamas and Fraser that many of the recurrent events are MI.6 Furthermore, the 5-year outcome meta-analysis demonstrated that even those in the lower third of risk had an absolute benefit of the interventional strategy of about 2% (reduced rates of death or MI) compared to a selective invasive strategy, and this benefit is of greater magnitude than seen in many trials of pharmacological therapies.6 Therefore, we agree with Mamas and Fraser that:

• Risk predictors should be used to inform clinical judgement, but individual patient characteristics need to be taken into consideration in treatment choices.

• Risk predictors need to consider the risk of death and the risk of future MI.

• Meta-analysis has demonstrated benefit for a routine interventional strategy in non-ST elevation ACS, sustained at 5 years. Absolute benefits are seen, even in those in the lowest third of risk.

Although these points do not relate directly to our editorial, we felt it important to address the points raised by Mamas and Fraser.