investigator variations in reporting. Improved methods for acquiring and possibly adjudicating bleeding events are required in this era of potent combination antithrombotic drugs. Conclusions Current definitions of MI used in trials of PCI account for about 13% of fatal events observed by 12 months. The combination of MI, bleeding and revascularisation accounts for about a quarter of the deaths observed by 12 months. These data support the current thresholds for defining ischaemic events in clinical trials and quality-of-care audits. More liberal definitions of bleeding may better identify patients at risk. Analysis by attributable risk may aid in the evaluation of end points selected for combination in composite primary end points used in future studies. ACKNOWLEDGEMENTS We thank Dr Adrian Esterman for his thoughtful review of the manuscript. Authors’ affiliations ..................... D P Chew, Flinders University, Adelaide, South Australia, Australia D L Bhatt, A M Lincoff, K Wolski, E J Topol, Cleveland Clinic Foundation, Cleveland, Ohio, USA The REPLACE-2 study was sponsored by The Medicines Company. No additional funding was provided for this analysis. The sponsors have had no influence over the conduct of this analysis or the interpretation of the results. REFERENCES 1 Brener SJ, Lytle BW, Schneider JP, et al. Association between CK-MB elevation after percutaneous or surgical revascularization and three-year mortality. J Am Coll Cardiol 2002;40:1961–7. 2 Abdelmeguid AE, Topol EJ. The myth of the myocardial ‘infarctlet’ during percutaneous coronary revascularization procedures. Circulation 1996;94:3369–75. 3 Kong TQ, Davidson CJ, Meyers SN, et al. Prognostic implication of creatine kinase elevation following elective coronary artery interventions. JAMA 1997;277:461–6. 4 Stone GW, Mehran R, Dangas G, et al. 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Background: Information about long term outcomes of patients with acute coronary syndromes (ACS) who have clinically diagnosed heart failure is scarce. Methods: In a UK registry, this study evaluated patients with non-ST elevation ACS, recording treatment, and clinical outcomes for six months. In a subgroup, a four year mortality follow up was performed to estimate the impact of the clinical diagnosis of heart failure on survival. Results: Of 1046 patients, 139 (13%) had a history of clinically diagnosed heart failure. At discharge, ACE inhibitors were prescribed for 58% and 28%, of those with and without a history of heart failure respectively (p,0.001). Rates of angiography, percutaneous intervention, and coronary artery bypass graft were 17.3% and 29.2% (p = 0.003), 5.0% and 8.4% (p = 0.17), and 5.0% and 7.5% (p = 0.3) for these groups respectively. Death or new myocardial infarction at six months occurred in 22% and 10% (p,0.001) and at four years death occurred in 60% and 20% of these groups respectively (p,0.001). In a multivariate analysis prior heart failure carried an odds ratio of 2.0 (p = 0.001) for death or myocardial infarction at six months and 2.4 (p,0.001) for death over four years. New heart failure was associated with an increased risk of death at six months (20% compared with 5%, p,0.001). Conclusion: A clinical history of heart failure carries a substantial risk of death in patients admitted with ACS without ST elevation. Nearly 60% of those with prior heart failure are dead after four years. After adjustment for confounding factors, prior heart failure more than doubles the risk compared with those with no history. m Postgraduate Medical Journal 2006;82:55–59. 950 Chew, Bhatt, Lincoff, et al www.heartjnl.com group.bmj.com on October 20, 2011 - Published by heart.bmj.com Downloaded from