Direct stenting: safe with advantages for the patient and for the doctor (less fluoroscopy and procedural time).

pattern — no improvement in early reperfusion, but there was a reduced rate of recurrent myocardial infarction. In streptokinase-treated patients, TIMI grade 3 flow at 20–28 h later tended to be higher in patients treated with dalteparin (68% vs 51% for unfractionated heparin, P=0·10), and the number of ischaemic episodes on continuous ECG monitoring was lower (16% vs 38%, P=0·04) with similar results recently presented in another study by Simoons and colleagues. Finally, the Assessment of the Safety and Efficacy of New Thrombolytic Regimens (ASSENT)-3 study compared three strategies in 6095 myocardial infarction patients: full-dose tenecteplase plus enoxaparin; half-dose tenecteplase plus weight-adjusted, reduced-dose, unfractionated heparin plus abciximab; and full-dose tenecteplase plus weight-adjusted, unfractionated heparin. Both new antithrombotic regimens showed a reduction in the combined endpoint of 30-day death, myocardial infarction, recurrent ischaemia or major bleeding (17·0% unfractionated heparin, 13·7% enoxaparin, and 14·2% abciximab). Although the rates of intracranial haemorrhage were the same for each group, there was a higher rate of major bleeding with abciximab. Thus, the most simple regimen appeared to have the best efficacy and safety profile — tenecteplase plus enoxaparin. However, this trial did not pre-specify a primary end-point or objective, and thus another large, prospective trial, using all thrombolytic regimens is needed to fully define the role of enoxaparin in ST segment elevation myocardial infarction. This is currently in the planning stages to be carried out by the TIMI group. C. P. CANNON The TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston MA, U.S.A.