A range of presentations of ischaemia is seen in acute coronary syndromes, from unstable angina at one end of the risk spectrum to myocardial infarction (with or without ST elevation) at the other. In all these disorders the risk of death is highest before admission to hospital, with mortality rates of up to 20%. Risk remains high after admission to hospital, and although mortality rates have fallen greatly in recent years,1 up to 7% of patients die before discharge, and risk continues to be high for six months after the ischaemic event.2 Minimising the risk of complications relies on identifying and treating patients at higher risk early on. In this week's BMJ, a multinational study by Fox and colleagues assesses the effectiveness of a risk prediction tool in estimating cumulative six month risk of death or myocardial infarction in people presenting with acute coronary syndrome.3

On presentation to hospital, patients are often triaged on the basis of concentrations of biomarkers and ST segment …