How soon after a patient with ST-Elevation Myocardial Infarction (STEMI) can they have a Percutaneous Coronary Intervention (PCI)?

From the Guidelines

Primary percutaneous coronary intervention (PCI) should be performed as soon as possible for patients with ST-elevation myocardial infarction (STEMI), ideally within 90 minutes of first medical contact for patients presenting to PCI-capable hospitals, or within 120 minutes for patients requiring transfer to a PCI-capable facility. This "door-to-balloon time" is critical because myocardial tissue death progresses rapidly during coronary occlusion, with irreversible damage occurring within hours. Earlier reperfusion significantly improves survival and reduces complications like heart failure 1. While awaiting PCI, patients should receive loading doses of antiplatelet therapy (aspirin 325 mg and either ticagrelor 180 mg, prasugrel 60 mg, or clopidogrel 600 mg), anticoagulation with unfractionated heparin, and pain management. If PCI cannot be performed within the recommended timeframes, fibrinolytic therapy should be considered if there are no contraindications, especially if the patient presents within 3 hours of symptom onset. The effectiveness of reperfusion therapy diminishes significantly after 12 hours from symptom onset, though some patients may still benefit from late PCI if they have ongoing symptoms or hemodynamic instability.

Some key points to consider:

• The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines recommend primary PCI for patients with STEMI and ischemic symptoms of less than 12 hours’ duration 1.
• The guidelines also recommend primary PCI for patients with STEMI and cardiogenic shock or acute severe heart failure, irrespective of time delay from MI onset 1.
• Fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact 1.
• The proposed time windows are system goals, and every effort should be made to provide reperfusion therapy as rapidly as possible 1.

The most recent and highest quality study, which is the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction, supports these recommendations 1.

From the FDA Drug Label

In patients with ST segment elevation MI (STEMI), consider extending duration of infusion following PCI at 1.75 mg/kg/h for up to 4 hours post-procedure. The answer to how soon after a patient with STEMI can have a PCI is not directly stated in the provided drug labels. However, it can be inferred that PCI can be performed immediately in patients with STEMI, as the drug label for bivalirudin discusses the administration of the drug during PCI, including in patients with STEMI.

• The exact timing of PCI after STEMI onset is not specified in the provided drug labels.
• The decision of when to perform PCI in a patient with STEMI should be made on a case-by-case basis, taking into account the individual patient's condition and medical history 2.

From the Research

Time to PCI in STEMI Patients

• The American College of Cardiology/American Heart Association guidelines recommend that percutaneous coronary intervention (PCI) should be performed within 90 minutes of first medical contact and total ischemic time should not exceed 120 minutes 3.
• A study found that only a small proportion of patients with acute myocardial infarction underwent primary PCI within the recommended time, with a median total ischemic time of 4 hours 30 minutes 3.
• The interval with the best performance was first medical contact to first ECG, with a median of 8 minutes, while the worst intervals were symptom onset to first medical contact and first ECG to PCI 3.
• Patients referred through the pre-hospital emergency system had shorter total ischemic time and door-to-balloon time compared to those from nearby hospitals 3.

Factors Affecting Time to PCI

• Symptom onset to first medical contact was the longest interval, with a median of 104 minutes, and only 6% of patients had a time of less than 30 minutes 3.
• First ECG to PCI was also a significant interval, with a median of 140 minutes, and only 16% of patients had a time of less than 90 minutes 3.
• The use of P2Y12 inhibitors, such as ticagrelor and prasugrel, has been shown to improve outcomes in STEMI patients, but may also increase the risk of bleeding 4, 5.

Importance of Timely PCI

• Rapid reperfusion is crucial in STEMI patients, as it can reduce the size of the infarct and improve outcomes 6.
• A study found that shorter total ischemic time was associated with better post-PCI TIMI flow, TIMI frame count, and ST-segment resolution 3.
• Timely PCI can also reduce the risk of major adverse cardiovascular events (MACE) and bleeding 4, 5.