Mitchell et al must be congratulated on their systematic review of myocardial revascularisation in patients with mental illness. ^{Reference Mitchell and Lawrence1} As physicians performing revascularisation procedures, we were disappointed by the inferior treatment received by patients with mental health problems. Fortunately, these patients account for only a minority of those presenting to acute cardiology services with symptoms and signs suggestive of acute coronary syndrome. However, when they do attend, they present cardiologists with a number of challenges, which ultimately can influence the decision regarding treatment.

Revascularisation remains an important treatment for those patients with myocardial necrosis, providing both symptomatic and prognostic benefit. ^{Reference Fox, Poole-Wilson, Henderson, Clayton, Chamberlain and Shaw2} Importantly, however, it can only be performed following invasive coronary angiography – a procedure which carries a risk of vascular complication, myocardial infarction, stroke or even death of 0.2–1.0%. Clearly, patients must give appropriate consent before coronary angiography is undertaken, and this can represent an important hurdle when treating patients with mental health problems.

A second important challenge which should be considered prior to undertaking angiography, and must be considered prior to performing definitive revascularisation, is the issue of adherence to medication. Frequently, revascularisation can be performed percutaneously at the time of angiography. This procedure usually necessitates the implanting of coronary stents, which are small permanent metal scaffolds that help maintain coronary vessel patency. There are many advantages to using these devices; however, in recent times stent thrombosis has emerged as the most serious and worrying complication of their use. ^{Reference Holmes, Kereiakes, Garg, Serruys, Dehmer and Ellis3} This condition is fortunately rare, but it remains a devastating, unpredictable event that has a significant morbidity and mortality; up to a third of patients will die. Research has identified that early or premature discontinuation of dual antiplatelet therapy is one of the most important risk factors in stent thrombosis. ^{Reference Daemen, Wenaweser, Tsuchida, Abrecht, Vaina and Morger4} Consequently, cardiologists are reluctant to implant stents in patients who they feel are unlikely to comply with dual antiplatelet therapy. Unfortunately, patients with mental illness have been shown to be less adherent to medication, ^{Reference Julius, Novitsky and Dubin5} a factor which certainly has as an influence on revascularisation decisions.

These issues represent important challenges (and not excuses), which must be overcome to allow our patients to receive the most appropriate treatment. The differences in treatment certainly deserve to be highlighted and as recommended by Mitchell et al the reasons behind them require more in depth investigation, especially within the confines of the National Health Service.