Timely and optimal treatment of patients with STEMI

Fibrinolysis is recommended in European and US guidelines for patients with ST-segment elevation myocardial infarction (STEMI) when a strategy of primary percutaneous coronary intervention (PPCI) is associated with ≥120 min delay from first medical contact (FMC), defined as call to the emergency medical services or self-presentation at hospital. Current evidence indicates that reperfusion therapy should be initiated as soon as possible after FMC. However, fibrinolysis cannot be initiated instantaneously at FMC, and PPCI is superior to fibrinolysis in reducing mortality if the extra time needed to perform PPCI instead of fibrinolysis (so-called PCI-related delay) is <120 min. During the past 10 years, the terms 'FMC-to-PPCI delay' and 'PCI-related delay' have been used in guidelines synonymously; however, a distinction should be made between the recommended FMC-to-PPCI delay and the acceptable PCI-related delay. In the future, an ideal recommendation would be to initiate reperfusion as soon as possible, preferably within 120 min of FMC in the case of PPCI. When the expected PCI-related delay is <120 min, PPCI should be the preferred reperfusion strategy, even if the FMC-to-PPCI delay is >120 min. Setting up a health-care system enabling prehospital diagnosis of STEMI with field triage of patients directly to catheterization laboratories at large-volume PCI centres (bypassing local hospitals, coronary care units, emergency departments, and intensive care units) will help to increase the proportion of patients with STEMI who will benefit from PPCI.