What are the recommended performance targets and key strategies for organizing STEMI networks in Asia to ensure primary percutaneous coronary intervention within 90 minutes (goal ≤60 minutes) and optimal door‑to‑balloon times?

STEMI Network Performance Targets and Organizational Strategies in Asia

Primary Performance Targets

For STEMI networks in Asia, the fundamental performance target is achieving primary PCI within 90 minutes of first medical contact for patients presenting to PCI-capable hospitals, with an aspirational goal of 60-70 minutes for optimized systems. 1 For patients requiring interhospital transfer from non-PCI-capable facilities, the extended target is 120 minutes from first medical contact to balloon inflation, though systems should still strive for ≤90 minutes. 1, 2

The 90-minute benchmark represents a systems goal that at least 75% of patients should achieve, recognizing that some patients will have unavoidable delays due to diagnostic uncertainty, anatomical challenges, or other clinical factors. 1 Advanced systems with refined protocols are achieving median door-to-balloon times of 60-70 minutes, which should be the aspirational target. 1

Essential Organizational Components

Network Structure Requirements

STEMI networks must establish clear designation of STEMI-receiving (PCI-capable) and STEMI-referral (non-PCI-capable) hospitals with formal transfer protocols. 1 The PCI-capable centers must meet specific volume and capability requirements:

• Institutional volume: ≥200 PCI procedures annually, with at least 36 being primary PCI for STEMI 1, 2
• Operator volume: Individual operators performing >75 PCI procedures per year, ideally ≥11 primary PCIs annually 1, 2
• 24/7 availability: Primary PCI capability must be available around the clock, seven days per week 1
• Cardiac surgery backup: On-site surgical capability is required 1, 2

Critical Time Interval Targets

The door-to-balloon time comprises three key components that networks must optimize:

• Door-to-ECG time: Should be ≤10 minutes, with best-performing systems achieving 3 minutes 1, 3
• ECG-to-catheterization laboratory activation: Target ≤5 minutes, with optimized systems achieving 3 minutes 3
• Laboratory arrival-to-balloon time: Target ≤20 minutes, with best systems achieving 16-17 minutes 3

For non-PCI-capable hospitals, the door-in-door-out time (arrival at referral hospital to departure for transfer) should be ≤30 minutes, with exemplary systems achieving 20-26 minutes. 1, 4

Key Implementation Strategies

Pre-Hospital System Integration

Emergency medical services must be equipped with 12-lead ECG capability and authority to activate the catheterization laboratory directly, bypassing the emergency department when appropriate. 1 This represents one of the most underutilized but effective strategies for reducing treatment delays. 1

• EMS personnel should transmit ECG findings to receiving hospitals for early catheterization laboratory activation 1
• Pre-hospital fibrinolytic capability should be available when transport times exceed targets 1
• Direct transport protocols to PCI-capable centers should be established for EMS-transported patients 1

Hospital-Level Process Optimization

The emergency physician must have authority to activate the catheterization laboratory with a single call, without requiring cardiology consultation first. 5 This single intervention is among the most impactful for reducing delays. The catheterization team must be prepared and ready within 20-30 minutes of activation. 5

Additional critical strategies include:

• Bypass emergency department protocols: STEMI patients should proceed directly to the catheterization laboratory when diagnosis is established pre-hospital 1
• Real-time data feedback systems: Continuous monitoring and reporting of door-to-balloon times to all team members drives sustained improvement 3, 6, 5
• Standardized activation protocols: Clear, written protocols eliminate ambiguity and reduce decision-making delays 6, 5

Quality Improvement Infrastructure

Networks must implement ongoing programs of outcomes analysis and periodic case review to identify process-of-care strategies for continuous improvement. 1 The Taiwan experience demonstrates that systematic quality improvement initiatives can increase the proportion of patients treated within 90 minutes from 46% to 80% within one year. 6

Essential quality components include:

• Regular team meetings: Multidisciplinary review of all STEMI cases, particularly those exceeding time targets 1
• Administrative support: Leadership commitment and resource allocation are mandatory for success 5
• Transparent performance reporting: Public reporting of institutional performance metrics drives accountability 1

Decision Algorithm for Reperfusion Strategy

For Patients Presenting to PCI-Capable Hospitals

Primary PCI should be performed within 90 minutes for all patients with symptom onset <12 hours. 1, 2 If this target cannot be consistently achieved, the institution should not serve as a STEMI-receiving center. 1, 2

For Patients Presenting to Non-PCI-Capable Hospitals

The decision pathway depends on multiple factors:

When transfer for primary PCI can achieve first medical contact-to-balloon time ≤120 minutes:

• Immediate transfer is the preferred strategy 1, 2
• Fibrinolytic therapy should NOT be administered 1

When transfer will result in first medical contact-to-balloon time >120 minutes:

• Administer fibrinolytic therapy within 30 minutes of hospital arrival (door-to-needle time) 1
• Transfer immediately after fibrinolysis for angiography within 2-24 hours 7

Special consideration for very early presenters (<2 hours from symptom onset):

• If expected door-to-balloon time minus expected door-to-needle time is >1 hour, fibrinolytic therapy is preferred even if transfer is possible 1, 7
• This reflects the critical importance of minimizing total ischemic time in the earliest hours 1

Critical Pitfalls and Solutions

Common System Failures

The most frequent causes of delay in Asian centers include late identification of STEMI patients, delays in obtaining ECG, and prolonged catheterization laboratory activation times. 8 A Saudi Arabian cardiac center study found only 25% of patients initially achieved the 90-minute target, with delays primarily due to these factors. 8

Transfer delays remain the Achilles heel of regional networks. 1 National registry data show that only 10% of transferred patients achieve 90-minute door-to-balloon times, with median times of 149 minutes. 1 This underscores the critical importance of either establishing robust rapid-transfer protocols or utilizing fibrinolytic therapy when transfer delays are unavoidable.

Avoiding Inappropriate Primary PCI

Hospitals and operators not meeting minimum volume requirements should not perform primary PCI. 1, 2 The benefit of primary PCI is not established when performed by operators doing <75 procedures annually or at centers performing <200 total PCIs with <36 primary STEMIs per year. 1, 2 These facilities should serve as STEMI-referral centers with fibrinolytic capability rather than attempting primary PCI.

Post-Fibrinolysis Management

All patients receiving fibrinolytic therapy must be transferred immediately to a PCI-capable center, regardless of apparent clinical success. 7 Routine angiography should be performed within 2-24 hours after fibrinolysis. 1, 7 Rescue PCI must be performed immediately if <50% ST-segment resolution occurs at 60-90 minutes post-fibrinolysis. 7

Performance Measurement and Accountability

Networks should establish the goal of treating at least 75% of patients within the 90-minute target, recognizing that some patients will have legitimate clinical reasons for delays. 1 This 75% threshold was specifically chosen to account for unavoidable patient-specific factors while maintaining high performance standards. 1

The measurement should focus on first medical contact-to-balloon time rather than door-to-balloon time alone, as this captures the entire system performance including pre-hospital care. 1 However, measurement methodology should not displace the emphasis on improving actual processes that facilitate more rapid, safe, and appropriate treatment. 1