This study has several limitations, similar to those reported by Rogers et al.21 Although large, the NRMI-I is an observational database rather than a randomized trial, and it is therefore more valuable for documenting practice patterns and temporal trends than for comparing effectiveness of various treatment interventions. Like many of the recent megatrials in thrombolysis, the data obtained on each NRMI-I patient had no independent validation of data forms, and there exists the potential for underreporting adverse events or for the enrollment of nonconsecutive patients. Also, although encompassing more than 1000 hospitals nationwide, NRMI-I hospitals are not necessarily representative of all US hospitals and likely reflect practice in larger, more procedure-related centers. The modest collection of demographic information in NRMI-I limits data interpretation. Although the percentage of use of aspirin, β-blockers, and other adjunctive therapy is likely to be correct, the presence of contraindications to these agents (that may, in part, explain their low use) was not recorded. These data are also limited in that potentially important confounding variables, such as the prevalence of diabetes, hypertension, tobacco use, and hyperlipidemia, were not recorded and hence could not be studied. Despite these limitations, the NRMI-I data reflect recent practice trends in more than 350000 patients and make compelling observations regarding the limited use of recommended adjunctive therapy. In the GUSTO trial,24 the use of β-blockers, heparin, and aspirin was standard protocol and the use of β-blockers in appropriate candidates was as high as 46% IV and 71% orally. Intravenous nitroglycerin was used in 77% of all patients. Recently, the GUSTO investigators reported outcomes in women,11 confirming their higher mortality rate compared with men. However, the authors did not comment on the percentage of use of such adjunctive therapy, which becomes particularly relevant (given the proven benefits of β-blocker use) if morbidity, in addition to mortality, is considered. In this article using data from the NRMI-I database, only in-hospital mortality is recorded and reported. When studying sex differences the GUSTO investigators11 reported 30-day mortality rates, limiting our ability to compare the NRMI-I data with those from the GUSTO trial. Furthermore, 30-day mortality rates may be additionally affected by adjunctive medical therapy. Our data suggest that in clinical practice in the United States, there may be an inappropriately conservative approach to the care of patients with AMI, especially in terms of using adjunctive therapy. This becomes particularly relevant in the case of women with MI, in which the actual use of β-blockers has been less than 50% of that reported in clinical trials. As supported by the multivariate analysis, this conservatism is associated with increased mortality and should be the focus of future studies.