What is the golden time for Acute Coronary Syndrome (ACS) management?

Golden Time for Acute Coronary Syndrome Management

For STEMI, primary PCI should be performed with a goal of first medical contact (FMC) to device activation of ≤90 minutes for direct presenters, or ≤120 minutes for patients requiring hospital transfer, to improve survival. 1

STEMI Time Targets

The "golden time" for STEMI represents critical time windows where reperfusion therapy maximizes survival:

Primary PCI Time Goals

• ≤90 minutes FMC-to-device for patients presenting directly to a PCI-capable center 1
• ≤120 minutes FMC-to-device for patients requiring transfer from a non-PCI-capable hospital 1
• Door-to-ECG ≤10 minutes upon hospital arrival 1

Fibrinolysis Time Goals (when PCI not feasible within target times)

• Door-to-needle ≤30 minutes for fibrinolytic administration 1
• Fibrinolysis should be considered if PPCI cannot be achieved within 120 minutes of FMC 1

Critical Context for Timing

• Every 10-minute delay in PPCI after 60 minutes from FMC results in an additional 3-4 deaths per 100 patients, with >80% mortality beyond 6 hours of delay in patients with cardiogenic shock 1
• The benefit of PPCI is most pronounced when performed <12 hours after symptom onset 1
• PPCI may still be reasonable 12-24 hours after symptom onset to improve clinical outcomes 1

NSTE-ACS Time Targets

The golden time concept differs substantially for NSTE-ACS (unstable angina/NSTEMI), as timing is risk-stratified rather than universally urgent:

Immediate Invasive Strategy (<2 hours)

Immediate coronary angiography is indicated for patients with: 1

• Refractory or recurrent angina despite optimal medical therapy
• Hemodynamic instability
• Electrical instability (life-threatening arrhythmias)
• Acute pulmonary edema or heart failure
• Worsening mitral regurgitation
• Cardiogenic shock

Early Invasive Strategy (≤24 hours)

Early angiography within 24 hours is reasonable for high-risk patients, particularly those with: 1

• GRACE risk score >140 (where early intervention reduces primary ischemic endpoints from 21.0% to 13.9%) 1
• Elevated cardiac biomarkers with continuing steep rise
• Diabetes mellitus
• Age >75 years
• Recurrent ischemia 1

Delayed Invasive Strategy (48-72 hours)

Delayed angiography within 48-72 hours is acceptable for intermediate- or low-risk patients without high-risk features, as timing does not appear critical in this population 1

Cardiogenic Shock: The Most Critical Golden Time

Emergency revascularization should be performed as soon as possible, ideally within 90 minutes, in patients with ACS and cardiogenic shock or hemodynamic instability, irrespective of time from symptom onset. 1 This represents the most time-sensitive ACS scenario with the highest mortality impact from delays.

Common Pitfalls to Avoid

• Do not delay STEMI reperfusion for "cooling off" periods or prolonged medical stabilization—every minute counts 1
• Do not apply STEMI time urgency to stable NSTE-ACS patients, as very early intervention (<24 hours) shows no benefit over delayed approach in low-risk patients 1
• Do not perform PCI on totally occluded infarct-related arteries >24 hours after symptom onset in stable patients without ongoing ischemia, severe heart failure, or life-threatening arrhythmias—there is no benefit 1
• Do not use weekend presentation as a reason to delay catheterization in appropriate candidates, as outcomes are equivalent when adjusted for timing 1

System-Level Implementation

Successful achievement of golden time targets requires: 1

• Prehospital ECG within 10 minutes of FMC by EMS 1
• Prehospital catheterization laboratory activation for suspected STEMI 1
• Direct transport to PCI centers when feasible, bypassing non-PCI-capable facilities 1
• Regional STEMI systems of care with robust data collection and process improvement mechanisms 1