Platelet glycoprotein IIb/IIIa receptor antagonists (GpRAs) are also associated with improved clinical outcomes in the setting of PPCI, with early delivery before the procedure improving the rate of epicardial patency at angiography, and conferring additional benefit. 7 Restoration of epicardial flow before the start of intervention is certainly associated with superior outcomes following PPCI, 8 and in this symposium Brodie has already discussed the facilitated approach with antecedent GpRAs, thrombolytic agents, or combined therapy. 9 Also in this symposium Prasad and Gersh have further emphasised the importance of looking beyond the epicardial vessel, to the microcirculation, in order to optimise outcomes. 10 Indeed, the clinical benefits of GpRAs may be partly mediated by improved microvascular perfusion. In the EMERALD (enhanced myocardial efficacy and recovery by aspiration of liberalized debris) study the PercuSurge GuardWire distal protection system (Medtronic, Santa Rosa, California, USA) used during PPCI less than six hours after presentation with STEMI did not improve angiographic perfusion scores, ST segment resolution, final infarct size, or clinical end points when compared to the results from a randomised control group. 16 Perhaps more surprising are the results of the recently presented AIMI study 17 where rheolytic thrombectomy (Angiojet, Possis) not only failed to improve the quality of reperfusion (despite a prior supportive study 18 ), but was also associated with a significant increase in mortality when compared with routine PPCI alone.