For ACS the guidelines from the American College of Cardiology/American Heart Association and of the European Society of Cardiology were revised in 2002. The paper is available on the web free (www.acc.org and www.escardio.org respectively) and one version of the ACC/AHA guideline highlights the changes made since the 2000 edition. Management of ACS has been complicated by divided opinion on whether treatment should be conservative or aggressive, a common dichotomy in medicine. The starting-point, back in 1997, for the TACTICS-TIMI 18 trial (paper #10)—an acronym of such unusual inelegance that I cannot bear to spell it out—was conservative. Management was essentially pharmacological, and invasive investigations and revascularization procedures were held in reserve.

This paper (#10) shifts the evidence towards a more aggressive policy, and it may even have influenced the way U.S. vice-president Dick Cheney’s 2000 infarct was handled. All 2,220 patients in TACTICS-TIMI 18 were given aspirin, heparin, and a member of a newish class of platelet inhibitors, tirofiban. They were then randomized to cardiac catheterization, followed, depending on the findings, by revascularization or to a policy of holding back on invasive procedures with stress-testing to screen for residual ischemia. The first group did much better at six months, not in survival but in respect of a combined, but predetermined, endpoint.

TACTICS-TIMI 18 coauthor, Dr. Christopher P. Cannon, reckons that opinion has now shifted. The paper has had a "big impact on clinical practice," he tells Science Watch, and he cites the updates in latest ACC/AHA guidelines as testimony of this impact. An early invasive strategy is the right approach for the ACS patient at high risk, as defined biochemically by the concentration of the marker troponin and electrocardiographically by ST segment depression. Today, we need to get this message across to hospital staff, Cannon says. And tomorrow? A recent excitement is the stent (an implanted vessel-dilating device) loaded with a drug such as sirolimus that leaches out from the stent and prevents the proliferation of tissue that bedevils revascularization efforts. This would make the early invasive strategy even more promising than was reported in this paper.

Atop the list, meanwhile, last summer's JAMA report from the Women’s Health Initiative, on hormone-replacement therapy, continues its impressive run as the most-cited paper in medicine (having been recognized by Science Watch, of course, as the most-cited non-review paper published in 2002). With its 100+ citations this time—the highest bimonthly total of any Top Ten report in this issue—the paper seems poised for a long reign.