In this issue (p 166) the GRACE investigators report a prospective cohort study comparing the outcomes of patients with acute coronary syndromes (ACS)—unstable angina or myocardial infarction with or without ST-segment elevation—admitted initially to hospitals with and without cardiac catheterization facilities. Their findings challenge us to think more deeply about how we interpret the results of recent clinical trials and translate them into practice.

Quantitative reviews1,2 of nearly two dozen clinical trials have compared primary percutaneous coronary intervention (PCI) to thrombolytic therapy for ST-elevation myocardial infarction (MI) and established that patients randomized to primary PCI had fewer deaths, subsequent nonfatal MIs, and hemorrhagic strokes, both in short-term (4-6 week) and long-term (6-18 month) follow-up. Early PCI is increasingly being favored for non-ST-elevation MI and unstable angina as well.3 Several studies have shown that the benefit of primary PCI can be realized even when the patient is admitted to a hospital without the capability of PCI and must be …