Cardiologists have for some time accepted that primary angioplasty, at least in the best hands, results in improved outcomes in patients with ST segment elevation myocardial infarction when compared to thrombolysis. An impasse had, however, arisen in the cardiology community. Primary angioplasty was regarded as the treatment that we would like to receive, and to offer, but the results of the well conducted trials have been regarded as impossible to translate into routine clinical practice. Arguments against the routine use of primary angioplasty had centred on the assumption that these results were only achievable in high volume centres manned by high quality staff. This year two landmark publications have forced us to radically reassess the role of primary angioplasty in the management of acute myocardial infarction. The first was a Lancet meta-analysis of 23 trials that demonstrated in the clearest terms yet the benefits of primary angioplasty.1 For every 50 patients treated, 1 life is saved. This mortality benefit is remarkable as primary angioplasty has been compared not to placebo but to a therapy, thrombolysis, with a well-documented mortality benefit of its own. Improved mortality was evident on both short- and long-term analyses. In the now vast world of clinical trials, benefit over and above efficacious therapy is notoriously difficult to demonstrate and is only rarely achieved. Patients treated with primary angioplasty also return less often with recurrent myocardial infarctions. One myocardial infarction is prevented for every 25 patients treated. Perhaps the most appealing finding for clinical cardiologists is the reduction in stroke frequency. One stroke is prevented for every 50 patients treated. While the meta-analysis convinced us of the benefits of angioplasty in good hands, it is a second …