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There were some high-level discussions in Britain when the RAF committed to bombing cities in 1941-42. Some scientists argued that not only was bombing incapable of causing catastrophic economic damage to Germany, but the morale effects were unlikely to match anticipations. This was based on a survey of residents of (I think) Birmingham and Hull, who were hit heavily during the Blitz, and their resilience. There was also discussion of the effects of bombing in Abyssinia, of Japan in China, and in Spain. Most subsequent discussion revolved around the anticipated effects on the war effort, but in the minutes of a high-level meeting in November 1942, we find this argument:

“There was, however, one strong argument in favour of this heavy air offensive which had not yet been mentioned; piecemeal devastation of German cities would bring the horrors of home to the German people in a way that had not hitherto been possible. They might in this way be made to realise that aggression did not pay.”

That sort of argument would tend to negate the importance of the British experience. Of course, these questions have been debated for many decades, and the general consensus seems to be that British bombing policy was mainly a function of prewar doctrines anticipating the devastating effects of bombing, which were entrenched in the politics of the RAF as an independent service; and in the imperative to show support to the Soviets. Updated studies of the effects of bombing would generally have been subordinated to those established motivations.

In the American case, I’ve run into a July 1945 study by political scientist Quincy Wright , “Historical Studies of Casualties,” which attempted to correlate casualty counts with capitulation in historical wars. Wright had already published a macro-historical comparative study of wars in 1942, A Study of War . I’m pretty sure this sort of study was inconsequential for policy, but it suggests that, at this time, the social-political dynamics of war were considered a pressing, unresolved problem, certainly academically.

In a notorious incident, the RAND Corporation later studied the circumstances of capitulation , including under what circumstances the US might consider capitulation – when this was learned by Congress, there were moves to defund the Air Force’s RAND contract.

Anyway, these are all isolated data points in a much larger picture of historical thought that remains to be synthesized. But it seems like something that can be profitably brought into the picture here.

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On your point about whether, by issuing a demonstration, the US would have been delineating an ethical line, which they might later be forced to cross in an indefensible way, I don’t quite see things the same way.

My sense has always been that the US-British response to the style of war in World War II – and particularly direct attacks on civilians – was that this kind of war was immoral, but that it had become necessary to avoid greater evil.

Considering the large number of patients and the heterogeneity of NSTE-ACS, early risk stratification is important to identify patients at high immediate and long-term risk of death and cardiovascular events, in whom an early invasive strategy with its adjunctive medical therapy may reduce that risk. It is equally important, however, to identify patients at low risk in whom potentially hazardous and costly invasive and medical treatments provide little benefit or in fact may cause harm.

Risk should be evaluated considering different clinical characteristics, ECG changes, and biochemical markers. Risk score models have therefore been developed. The ESC Guidelines for NSTE-ACS recommend the GRACE risk score ( http://www.outcomes-umassmed.org/grace ) as the preferred classification to apply on admission and at discharge in daily clinical practice [ 60 ]. The GRACE risk score was originally constructed for prediction of hospital mortality but has been extended for prediction of long-term outcome across the spectrum of ACS and for prediction of benefit with invasive procedures [ 61 ].

A substantial benefit with an early invasive strategy has only been proved in patients at high risk. The recently published meta-analysis [ 59 ] including the FRISC II [ 62 ], the ICTUS [ 63 ], and the RITA III [ 64 ] trials showed a direct relationship between risk, evaluated by a set of risk indicators including age, diabetes, hypotension, ST depression, and body mass index (BMI), and benefit from an early invasive approach.

Troponin elevation and ST depression at baseline appear to be among the most powerful individual predictors of benefit from invasive treatment. The role of high sensitivity troponin measurements has yet to be defined.

The issue of the timing of invasive investigation has been a subject of discussion. A very early invasive strategy, as opposed to a delayed invasive strategy, has been tested in five prospective RCTs ( Table 10 ).

Table 10
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Randomized clinical trials comparing different invasive treatment strategies

Table 10
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Randomized clinical trials comparing different invasive treatment strategies

A wealth of data supports a primary early invasive strategy over a conservative strategy. There is no evidence that any particular time of delay to intervention with upstream pharmacological treatment, including intensive antithrombotic agents, would be superior to providing adequate medical treatment and performing angiography as early as possible [ 65 ]. Ischaemic events as well as bleeding complications tend to be lower and hospital stay can be shortened with an early as opposed to a later invasive strategy. In high-risk patients with a GRACE risk score > 140, urgent angiography should be performed within 24h if possible [ 66 ].

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