• Heart rate variability
• nitrites
• oxidative stress
• atherosclerosis
• risk factors
• acute coronary syndrome
• reperfusion
• nstemi
• angina—unstable

Despite recent substantial advances in risk factor management and cardiac care, the incidence of myocardial infarction remains a major public health concern across the globe. Recent European registry data demonstrate the incidence of all acute myocardial infarction to be around 190/100 000 people/year, with ST segment elevation myocardial infarction (STEMI) representing around 40% of that number.1 In multiple clinical trials, primary percutaneous coronary intervention (PCI) has been shown to be better than thrombolysis in the treatment of STEMI, and indeed the ESC, ACC and AHA all recommend primary PCI as first-line reperfusion treatment.2 3 Although primary PCI is first line of treatment for STEMI, adjuvant antithrombotic pharmacotherapy varies widely, and the optimal antithrombotic regimen is still the source of debate as head-to-head trial evidence of all the options is limited.

Recent studies have demonstrated that the use of bivalirudin, a hirudin-type drug which acts as a direct thrombin inhibitor, before and during primary PCI is associated with reduced cardiovascular mortality and morbidity as compared with the use of unfractionated heparin and GpIIb/IIIa inhibitors.4 In the open-label HORIZONS-AMI trial, 3602 patients presenting with STEMI were randomised to receive either bivalirudin or unfractionated heparin with a GpIIb/IIIa inhibitor as adjunctive antithrombotic treatment. The authors prespecifed two primary end points, the incidence of major bleeding and a composite end point of the combination of major bleeding and the incidence of major adverse cardiovascular events, including death, reinfarction, target vessel revascularisation for ischaemia and stroke. They demonstrated a 24% RR reduction (9.2% vs 12.1%) in the composite end point in the bivalirudin group as …