What is the current recommendation for STEMI (ST-Elevation Myocardial Infarction) patients with multivessel disease when PCI (Percutaneous Coronary Intervention) is not immediately feasible due to lack of facility?

STEMI with Multivessel Disease When PCI is Not Feasible

Administer fibrinolytic therapy immediately (within 30 minutes of hospital arrival) and arrange urgent transfer to a PCI-capable center for angiography within 3-24 hours after fibrinolysis. 1

Immediate Reperfusion Strategy

When PCI cannot be performed within 120 minutes of first medical contact due to lack of facility, fibrinolytic therapy becomes the primary reperfusion strategy for STEMI patients, regardless of whether multivessel disease is present. 2, 1

Key time-dependent actions:

• Administer fibrinolytic therapy within 30 minutes of hospital arrival if no contraindications exist and symptoms began within 12 hours. 2
• Use fibrin-specific agents (alteplase, tenecteplase, or reteplase) rather than streptokinase for superior outcomes. 1
• Initiate transfer arrangements immediately during or right after fibrinolytic administration—do not wait to see if fibrinolysis works. 1

The Pharmaco-Invasive Approach

The current ESC-aligned strategy emphasizes a pharmaco-invasive approach rather than fibrinolysis alone, which is particularly relevant for resource-limited settings. 2, 1

This means:

• Fibrinolysis serves as immediate reperfusion therapy to restore flow quickly. 2
• Routine transfer for angiography occurs within 3-24 hours regardless of apparent fibrinolysis success. 2, 1
• This combined strategy achieves outcomes comparable to primary PCI when executed properly. 1

The evidence strongly supports routine early angiography after fibrinolysis rather than waiting for ischemia-driven indications. 2 Waiting only for rescue PCI (when fibrinolysis fails) results in worse outcomes compared to planned early angiography for all patients. 2

Multivessel Disease Considerations

The presence of multivessel disease does not change the initial reperfusion strategy when PCI is unavailable. 3

Critical points:

• Fibrinolysis targets the culprit vessel causing the STEMI, which is appropriate initial management. 3
• Decisions about non-culprit vessel revascularization occur during the subsequent angiography at the PCI-capable center, not during the acute phase. 3, 4
• Current evidence favors staged multivessel PCI (treating non-culprit vessels days to weeks after the index event) over immediate complete revascularization during the initial procedure. 4

Time Windows and Decision Framework

For patients presenting within 2 hours of symptom onset:

• Fibrinolysis is reasonable when expected delay to PCI exceeds 60 minutes. 2

For patients presenting 2-3 hours after symptom onset:

• Either fibrinolysis or transfer for PCI is acceptable when PCI delay is 60-120 minutes. 2

For patients presenting 3-12 hours after symptom onset:

• Transfer for PCI is preferred if achievable within 120 minutes; otherwise, fibrinolysis should be administered. 2

For patients presenting >12 hours after symptom onset:

• Fibrinolysis effectiveness diminishes significantly, but may still be considered if large myocardium is at risk, hemodynamic instability exists, and PCI remains unavailable. 2

Adjunctive Therapy

Antiplatelet regimen:

• Aspirin 150-325 mg immediately (oral or IV). 1
• Clopidogrel 300 mg loading dose (anticipating subsequent PCI). 1

Anticoagulation:

• Enoxaparin (preferred) or weight-adjusted unfractionated heparin. 1, 5

Monitoring and Rescue Strategy

Assess ST-segment resolution at 60-90 minutes post-fibrinolysis. 1

• <50% ST-segment resolution indicates failed reperfusion and necessitates immediate rescue PCI if transfer can be expedited. 1
• ≥50% ST-segment resolution suggests successful reperfusion, but routine angiography within 3-24 hours remains indicated. 2, 1

Critical Contraindications to Screen

Before administering fibrinolysis, rapidly exclude:

• Active bleeding or bleeding diathesis. 1
• History of intracranial hemorrhage or any stroke. 1
• Recent major surgery or trauma (<3 weeks). 1
• Suspected aortic dissection (especially critical in hypotensive patients). 1

Common Pitfalls to Avoid

Do not delay fibrinolysis while arranging transfer. The 2015 International Consensus explicitly recommends against immediate transfer without fibrinolysis when PCI delays exceed 120 minutes. 2 Every 30-minute delay in reperfusion increases mortality. 1

Do not administer fibrinolysis and then perform immediate PCI. This "facilitated PCI" approach increases bleeding and ischemic complications without mortality benefit. 2

Do not keep patients at the non-PCI facility after fibrinolysis for observation. Transfer should be arranged immediately, with angiography planned within 3-24 hours regardless of clinical stability. 2, 1

Do not attempt immediate complete revascularization of all vessels during the first PCI. Evidence suggests staged procedures for non-culprit vessels yield better outcomes than immediate multivessel intervention. 4