Acute coronary syndromes.

Temporal trends for the global coronary epidemic vary by region but in most developed countries mortality is in decline.1 Life style adjustments have contributed to this decline, most recently the implementation of comprehensive smoke-free legislation in many countries that has already caused significant reductions in acute coronary events.2 Smoking, a potent thrombogenic stimulus, is a major determinant of ST elevation myocardial infarction (STEMI)3 and a recent analysis from Kaiser Permanente in California –where smoke-free legislation is strictly enforcedshowed a 62% decline in STEMI between 1999 and 2008 while non-ST elevation myocardial infarction (NSTEMI) increased by 30%.4 overall, there was a 24% reduction in hospitalizations for acute coronary syndromes despite lowering of diagnostic thresholds by sensitive troponin biomarkers.5 This was accompanied by improvement in the age and sex adjusted 30-day mortality from 10.5% in 1999 to 7.8% in 2008. Increasing rates of interventional management no doubt contributed to the improved outcomes but parallel increases in plaque stabilising treatment with high-dose statins must also have played a role6 because vulnerable thin-cap fibroatheromas, often remote from the infarct-related artery and unrelated to stenosis severity, are the sites at which recurrent plaque events usually occur.7,8 Diagnosis