In the linked study (doi:10.1136/bmj.d3527), James and colleagues report a planned subgroup analysis of patients enrolled in the PLATelet inhibition and patient Outcomes (PLATO) trial, who at randomisation were initially allocated to a non-invasive treatment strategy. They compared cardiovascular outcomes and major bleeding in people treated with aspirin who were randomised to receive ticagrelor or clopidogrel.1

Interventional management is recommended for most patients with acute coronary syndromes, but a more conservative approach can be taken in certain subgroups. For example, in ST elevation myocardial infarction, thrombolytic treatment is an option for patients who present one to two hours after the onset of symptoms when primary percutaneous intervention is not immediately available.2 Conservative management is also an option in some low risk groups with non-ST elevation myocardial infarction and unstable angina if the risk of intervention exceeds the benefit.3 Patients unwilling to accept intervention or with prohibitive comorbidities add to the requirement for effective, stand alone medical strategies: the Myocardial Ischaemia National Audit Project for England and Wales found that in 2009-10 about 35% of patients with ST elevation myocardial infarction and 36.4% with non-ST elevation myocardial infarction did not have angiography during the initial hospital admission.4

Antiplatelet treatment with aspirin …