From the Guidelines
Patients with a STEMI should ideally be transported directly to a PCI-capable hospital for primary percutaneous coronary intervention (PCI) if possible within 120 minutes of first medical contact, as this approach minimizes the time to coronary reperfusion and improves survival outcomes. The most recent and highest quality study, 1, published in 2017, recommends primary PCI as the preferred method of reperfusion when it can be performed in a timely fashion by experienced operators, with a Class I, Level of Evidence: A recommendation.
Key Considerations
- The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines, 1, emphasize the importance of minimizing the "door-to-balloon time" to under 90 minutes, as every 30-minute delay in reperfusion increases mortality risk.
- If direct transport to a PCI-capable facility is not possible within 120 minutes, patients should first go to the ER for initial stabilization and fibrinolytic therapy, such as alteplase, with aspirin, a P2Y12 inhibitor, and anticoagulation with unfractionated heparin.
- The guidelines also recommend immediate transfer to a PCI-capable hospital for primary PCI for patients with STEMI who initially arrive at or are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less, 1.
Treatment Approach
- Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration, with a Class I, Level of Evidence: A recommendation, 1.
- Fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes, with a Class I, Level of Evidence: B recommendation, 1.
- The treatment approach should prioritize rapid restoration of coronary blood flow to salvage myocardium and improve survival outcomes, as supported by the guidelines, 1.
From the Research
Optimal Treatment Strategy for STEMI Patients
- The optimal treatment strategy for patients with ST-Elevation Myocardial Infarction (STEMI) involves rapid transport to a percutaneous coronary intervention (PCI) center by Emergency Medical Services, with prehospital diagnosis and activation of the cardiac catheterization laboratory 2.
- Primary PCI with stent implantation as soon as possible is the best treatment strategy for patients with STEMI 2.
- The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines recommend that PCI should be performed within 120 minutes from first medical contact, and door-to-balloon time should be <60 minutes in order to reduce long term mortality 3, 4.
Direct Transport to Cardiac Catheterization Laboratory
- Direct transport of patients with STEMI to the cardiac catheterization laboratory, bypassing the emergency room, can significantly reduce door-to-balloon times compared to established standard processes-of-care for patients considered for primary PCI 5.
- A study found that median door-to-balloon time was reduced by 27 minutes when patients with STEMI were transported directly to the cardiac catheterization laboratory 5.
- The ESC guidelines recommend that patients with STEMI should be admitted directly to the catheterization laboratory, bypassing the emergency room or intensive care unit, to minimize delays in treatment 6.
Prehospital Diagnosis and Triage
- Prehospital diagnosis of STEMI using electrocardiogram (ECG) can help identify patients who require immediate transport to a PCI center 4.
- A regional STEMI network with prehospital diagnosis and triage of patients can lead to significant improvements in the standard of therapy for acute myocardial infarction patients, resulting in historically low 30-day mortality rates for STEMI patients 4.
- Air transfer using helicopter emergency medical services can reduce transfer times and improve survival rates for STEMI patients, especially those located at distant sites 4.