Reperfusion Deadlines for ACS (2025 AHA Guidelines)
The interval between first medical contact and reperfusion should not exceed 120 minutes, regardless of whether time of symptom onset is known. 1
Primary PCI Time Targets
For PCI-capable hospitals:
- Door-to-balloon time ≤90 minutes from first medical contact 1, 2, 3
- For patients presenting directly to a PCI-capable facility, achieve primary PCI within 60 minutes of first medical contact 1, 2
For non-PCI-capable hospitals requiring transfer:
- First medical contact-to-device time ≤120 minutes (includes transfer time) 1, 2, 3
- Time from first hospital door to balloon inflation in second hospital should be <90 minutes 2
Fibrinolytic Therapy Time Target
Door-to-needle time ≤30 minutes when fibrinolysis is the chosen reperfusion strategy 1
Time-Dependent Decision Algorithm
For patients presenting <2 hours from symptom onset:
- Immediate fibrinolysis may be considered when expected delay to PCI exceeds 60 minutes 1
- This is particularly important for patients with large infarct area and low bleeding risk 2
For patients presenting 2-3 hours from symptom onset:
- Either immediate fibrinolysis or PCI with possible delay of 60-120 minutes might be reasonable 1
For patients presenting 3-12 hours from symptom onset:
- PCI involving possible delay up to 120 minutes may be considered rather than fibrinolysis 1
- Fibrinolysis becomes significantly less effective >6 hours after symptom onset, making longer delays to PCI acceptable in this timeframe 1
When delays to PCI exceed 120 minutes:
- Immediate fibrinolysis followed by routine early angiography (within 3-24 hours) and PCI if indicated is reasonable 1
Transfer Strategy from Non-PCI Hospitals
Immediate transfer without fibrinolysis is recommended from non-PCI-capable hospitals to PCI centers instead of immediate fibrinolysis at the initial hospital 1
Exception: When STEMI patients cannot be transferred to a PCI-capable hospital in a timely manner (≤120 minutes), fibrinolytic therapy with routine transfer for angiography may be acceptable 1
Critical Time-Independent Indications for PCI
Primary PCI is recommended regardless of time delays for: 2, 3
- Cardiogenic shock
- Contraindications to fibrinolytic therapy
- Severe congestive heart failure
ECG Acquisition Deadline
Obtain and interpret 12-lead ECG within 10 minutes of first medical contact 1, 2, 3
Post-Fibrinolysis Angiography Window
For patients receiving fibrinolysis, perform angiography within 3-24 hours 1
Rescue PCI timing: Assess for <50% ST-segment resolution 60-90 minutes after fibrinolysis initiation 2
Critical Pitfalls to Avoid
- Never delay ECG acquisition beyond 10 minutes of first medical contact 2, 3
- Do not wait for cardiac biomarker results before making transfer decisions 2
- Mortality increases significantly with each 15-minute delay in door-to-TIMI-3 flow time 2
- Each 30-minute delay from symptom onset to balloon inflation increases 1-year mortality (relative risk 1.08) 2
- Do not choose primary PCI over fibrinolysis when door-to-balloon time will exceed door-to-needle time by >60 minutes in patients presenting <3 hours from symptom onset 2
- Avoid facilitated PCI (full-dose or half-dose lytic therapy before planned PCI), which shows no mortality benefit but increased bleeding complications 2