Emergent PCI protocols and door-to-balloon time management
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Nehal Eid, M.D.[2]
Overview
Emergent percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction (STEMI). The concept of door-to-balloon (D2B) time refers to the interval from a patient's arrival at the hospital to the inflation of the first balloon (or activation of the first device) to restore coronary blood flow. Timely primary PCI (PPCI) confers improved survival compared with fibrinolytic therapy and is the cornerstone of modern STEMI management.[1]
The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes recommends a first medical contact (FMC)-to-device activation time of ≤90 minutes for patients presenting to a PCI-capable hospital and ≤120 minutes for patients requiring interhospital transfer.[1] Systems of care designed to reduce the time to PPCI have been consequential in reducing the risk of early death in patients with STEMI.
Historical Perspective
The importance of timely reperfusion in acute myocardial infarction was established through landmark trials comparing primary PCI with fibrinolytic therapy. The Danish Acute Myocardial Infarction 2 (DANAMI-2) trial randomized 1,572 patients with STEMI to fibrinolysis or primary PCI and demonstrated a significant benefit of PCI over fibrinolysis, with 16-year cardiac mortality rates of 18.3% versus 22.7%.[2]
In 2006, the American Heart Association launched the Mission: Lifeline program, involving EMS and clinicians with practiced drill-down programs and regionalization of care, which improved myocardial salvage and reduced the risk of death and adverse outcomes.[1] By 2009, more than 80% of patients undergoing primary PCI for STEMI in the United States met the guideline goal of a D2B time of 90 minutes or less.[3]
Pathophysiology
The rationale for emergent PCI is based on the principle that prolonged myocardial ischemia leads to progressive cardiomyocyte death, beginning in the subendocardium and extending transmurally over time. Timely restoration of coronary blood flow through mechanical reperfusion limits infarct size, preserves left ventricular function, and reduces mortality. The relationship between ischemic time and myocardial salvage is time-dependent, with the greatest benefit observed when reperfusion is achieved early after symptom onset.
Coronary no-reflow, defined as the lack of antegrade coronary flow in the absence of epicardial obstruction, occurs in approximately 4% of patients undergoing primary PCI and is associated with larger infarct size and increased long-term mortality.[4] The primary basis for no-reflow is microvascular obstruction (MVO), with pathologic mechanisms including ischemia/reperfusion injury, endothelial dysfunction, microvascular spasm, interstitial edema, intramyocardial hemorrhage, and distal thromboembolization.[5]
Time Metrics and Definitions
Several time intervals are used to measure the efficiency of STEMI care systems:
| Time Metric | Definition | Guideline Target |
|---|---|---|
| First Medical Contact (FMC)-to-Device Time | Time from initial contact with a healthcare provider (EMS or ED) to first device activation in the catheterization laboratory | ≤90 minutes (direct presentation); ≤120 minutes (transfer patients) |
| Door-to-Balloon (D2B) Time | Time from hospital arrival to first balloon inflation or device activation | ≤90 minutes |
| Door-in-Door-out (DIDO) Time | Time from arrival at a non-PCI-capable hospital to departure for transfer | ≤30 minutes |
| Door-to-Needle (DTN) Time | Time from hospital arrival to initiation of fibrinolytic therapy | ≤30 minutes (when fibrinolysis is chosen) |
| Onset-to-Door (O2D) Time | Time from symptom onset to hospital arrival | Minimize through public education |
| Total Ischemic Time | Time from symptom onset to reperfusion | Minimize |
Indications for Emergent PCI
Primary PCI in STEMI
The 2025 ACC/AHA guideline provides the following recommendations for PPCI in STEMI (Class of Recommendation [COR] and Level of Evidence [LOE] noted):[1]
| COR | LOE | Recommendation |
|---|---|---|
| 1 | A | In patients with STEMI presenting <12 hours after symptom onset, PPCI should be performed with a goal of FMC-to-device activation of ≤90 minutes, or ≤120 minutes in patients requiring hospital transfer, to improve survival. |
| 1 | B-R | In patients with ACS and cardiogenic shock or hemodynamic instability, emergency revascularization of the culprit vessel by PCI or CABG is indicated to improve survival, irrespective of time from symptom onset. |
| 2a | B-NR | In patients with STEMI presenting 12 to 24 hours after symptom onset, PPCI is reasonable to improve clinical outcomes. |
| 2a | C-LD | In patients with STEMI presenting >24 hours after symptom onset with ongoing ischemia or life-threatening arrhythmia, PPCI is reasonable to improve clinical outcomes. |
| 3: No Benefit | B-R | In stable patients with STEMI who have a totally occluded infarct-related artery >24 hours after symptom onset without evidence of ongoing ischemia, acute severe heart failure, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit. |
Fibrinolytic Therapy as an Alternative
When PPCI cannot be achieved within 120 minutes of FMC, fibrinolytic therapy should be administered in patients with STEMI and symptom onset <12 hours who have no contraindications (COR 1, LOE A).[1] Fibrin-specific agents are preferred over non-fibrin-specific agents due to superior patency rates.[1]
Regional Systems of STEMI Care
Key Components
The 2025 ACC/AHA guideline and the 2021 AHA Policy Statement on Systems of Care for STEMI emphasize the following components of an effective regional STEMI system:[1][6]
Prehospital ECG acquisition and interpretation: EMS personnel should acquire a 12-lead electrocardiogram at the site of first medical contact. Three methods are recommended for interpretation: computer algorithm, trained paramedic read, or transmission for physician interpretation.
Prehospital catheterization laboratory activation: Activation of the catheterization laboratory from the field has been associated with lower short- and long-term mortality in patients presenting with STEMI.
Direct transport to PCI-capable hospitals: Direct transfer to a PCI-capable facility has been associated with shorter reperfusion times and lower mortality compared with transport to the closest non-PCI-capable hospital.
Single-call transfer protocols: A single-call activation approach reduces the transfer burden for both the receiving and referring facility.
Emergency department bypass: Transport of patients directly to the catheterization laboratory for those presenting by EMS to a PCI-capable hospital.
Strategies to Reduce Door-to-Balloon Time
A landmark study by Bradley et al. (2006) identified several hospital strategies associated with significant reductions in D2B time:[7]
| Strategy | Estimated D2B Time Reduction |
|---|---|
| Emergency medicine physician activates catheterization laboratory | −8.2 minutes |
| Single-call activation system (ED calls central page operator who pages interventionalist and catheterization laboratory staff) | −13.8 minutes |
| ED activates catheterization laboratory while patient is still en route | −15.4 minutes |
| Expected catheterization laboratory staff arrival ≤20 minutes (vs. >30 minutes) | −19.3 minutes (difference) |
| Attending cardiologist always present at hospital | −14.6 minutes |
| Real-time data feedback to ED and catheterization laboratory staff | −8.6 minutes |
Many institutions are regularly achieving D2B times of <60 minutes, and consideration should be given to this potential new standard during quality improvement reviews.[6]
Transfer Protocols for Non-PCI-Capable Hospitals
For patients presenting to a non-PCI-capable hospital:[1]
If FMC-to-device activation can be achieved within ≤120 minutes, transfer for PPCI is recommended (COR 1, LOE A).
If anticipated delay to PPCI exceeds 120 minutes from FMC and symptom onset is <12 hours, fibrinolytic therapy should be administered (COR 1, LOE A).
The DIDO time goal is ≤30 minutes.
Receiving centers should have a door-to-device time goal of ≤30 minutes for transfer patients.
Prearranged acceptance agreements, direct communication between facilities, prehospital registration, and direct-to-catheterization-laboratory transport should be established.
Treatment
Initial Management
Prehospital and Emergency Department
Obtain a 12-lead electrocardiogram within 10 minutes of FMC.
Activate the catheterization laboratory immediately upon STEMI recognition.
Administer aspirin loading dose of 162 to 325 mg orally (nonenteric coated, chewed when possible) as soon as possible (COR 1, LOE A).[1]
Administer a P2Y12 inhibitor loading dose as early as possible or at the time of PCI (COR 1, LOE B-R for STEMI managed with PPCI):[1]
Prasugrel 60 mg orally, or
Ticagrelor 180 mg orally
Clopidogrel 600 mg orally (when prasugrel or ticagrelor are unavailable, cannot be tolerated, or are contraindicated)
Prasugrel is contraindicated in patients with prior stroke or transient ischemic attack (COR 3: Harm).
Prasugrel maintenance dose: 10 mg orally daily if body weight ≥60 kg and age <75 years; 5 mg orally daily if body weight <60 kg or age ≥75 years (use caution).[1]
Aspirin doses of ≤100 mg daily should be used in patients treated with ticagrelor.
Anticoagulation
Parenteral anticoagulation should be administered at the time of PCI:[1][8]
| Agent | Dosing | Notes |
|---|---|---|
| Unfractionated heparin (UFH) | Without GP IIb/IIIa inhibitor: 70-100 U/kg IV bolus to achieve therapeutic ACT; With GP IIb/IIIa inhibitor: 50-70 U/kg IV bolus | COR 1 |
| Bivalirudin | 0.75 mg/kg IV bolus, then 1.75 mg/kg/h infusion | COR 1, LOE B-R; useful as an alternative to UFH to reduce mortality and bleeding in STEMI patients undergoing PCI |
| Enoxaparin (IV) | Per institutional protocol | COR 2b, LOE B-R; may be considered as an alternative to UFH at the time of PCI |
| Fondaparinux | — | COR 3: Harm; should not be used to support PCI because of the risk of catheter thrombosis |
Procedural / Surgical Therapy
Vascular Access
The 2025 ACC/AHA guideline recommends radial artery access for PCI in patients with ACS (COR 1, LOE A).[1] A meta-analysis of individual patient data from 7 randomized controlled trials demonstrated that radial access was independently associated with a 24% relative risk reduction in all-cause death and a 51% relative risk reduction in major bleeding compared with femoral artery access. Vascular complications were reduced by 62%. The MATRIX trial demonstrated a significantly lower rate of net adverse clinical events among patients with ACS randomized to the transradial approach compared with the transfemoral approach.[1]
Stent Selection
Drug-eluting stents are the standard of care for primary PCI in STEMI. Bare-metal stents are no longer routinely recommended given the superior outcomes with drug-eluting stents.
Multivessel Disease
In patients with STEMI and multivessel coronary artery disease, complete revascularization is recommended to reduce the risk of cardiovascular death or myocardial infarction (COR 1, LOE A).[1] The COMPLETE trial randomized 4,041 patients with STEMI and significant multivessel disease to staged PCI of the non-infarct-related artery (performed up to 45 days post-MI) versus culprit vessel-only revascularization. At a median follow-up of 3 years, multivessel PCI reduced cardiovascular death or MI.[9]
The MULTISTARS AMI trial demonstrated that immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the composite of death, nonfatal MI, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year.[10]
In patients with ACS complicated by cardiogenic shock, routine PCI of a noninfarct-related artery at the time of PPCI should not be performed because of the higher risk of death or renal failure (COR 3: Harm, LOE B-R).[1]
Management of No-Reflow
Prevention and early recognition are the foundations of no-reflow management. Strategies include:[5]
Careful assessment for thrombus after initial wiring
Maneuvers to treat thrombus (aspiration, pharmacologic)
Exclusion of coronary artery dissection, which can mimic no-reflow
Intracoronary vasodilators (e.g., adenosine, nitroprusside, verapamil) may be considered, although no therapy has been found to consistently prevent or reverse no-reflow
Medical Therapy
Fibrinolytic Therapy (When PPCI Is Not Available)
When PPCI cannot be performed within 120 minutes of FMC, fibrinolytic therapy should be administered. Fibrin-specific agents are preferred:[1]
| Agent | Dose |
|---|---|
| Tenecteplase (TNK-tPA) | Single IV weight-based bolus: 30 mg for weight <60 kg; 35 mg for 60-69 kg; 40 mg for 70-79 kg; 45 mg for 80-89 kg; 50 mg for ≥90 kg |
| Reteplase (rPA) | Two 10-unit IV boluses given 30 minutes apart (each administered over 2 minutes) |
| Alteplase (tPA) | 90-minute weight-based infusion: Adults ≥67 kg: 15 mg IV bolus, then 50 mg IV over 30 minutes, then 35 mg IV over 60 minutes (total 100 mg). Adults <67 kg: 15 mg IV bolus, then 0.75 mg/kg IV (not to exceed 50 mg) over 30 minutes, then 0.5 mg/kg IV (not to exceed 35 mg) over 60 minutes |
For patients ≥75 years of age receiving fibrinolytic therapy, half-dose tenecteplase may be considered.[2]
Adjunctive antiplatelet therapy with fibrinolytic therapy: clopidogrel is recommended (COR 1, LOE A). Loading dose of 300 mg orally if age ≤75 years; initial dose of 75 mg orally (without loading dose) if age >75 years. Maintenance dose: 75 mg orally daily.[1]
Contraindications to Fibrinolytic Therapy
| Absolute Contraindications | Relative Contraindications |
|---|---|
|
Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g., arteriovenous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months (except acute ischemic stroke) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months Severe uncontrolled hypertension (unresponsive to therapy; SBP >180 mm Hg or DBP >110 mm Hg) |
History of chronic, severe, poorly controlled hypertension Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) History of prior ischemic stroke >3 months Known intracranial pathology not covered in absolute contraindications Traumatic or prolonged (>10 minutes) CPR Major surgery (<3 weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures Active peptic ulcer Oral anticoagulant therapy |
Coronary Angiography After Fibrinolytic Therapy
All patients receiving fibrinolytic therapy should be transferred to a PCI-capable hospital:[1]
Transfer immediately after fibrinolytic therapy is recommended (COR 1, LOE A).
In patients with suspected failed reperfusion (persistent ST-segment elevation, ongoing ischemic symptoms, hemodynamic or electrical instability), immediate angiography with rescue PCI is recommended (COR 1, LOE B-R).
In patients with successful fibrinolysis, early angiography between 2 and 24 hours with intent to perform PCI is recommended (COR 1, LOE B-R).
Long-Term Management
Dual Antiplatelet Therapy (DAPT)
In patients with ACS who are not at high bleeding risk, DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 12 months to reduce MACE (COR 1, LOE A).[1]
Maintenance dosing:
Aspirin: 75-100 mg orally daily (nonenteric coated)
Clopidogrel: 75 mg orally daily
Prasugrel: 10 mg orally daily (5 mg daily if body weight <60 kg or age ≥75 years)
Ticagrelor: 90 mg orally twice daily
Bleeding reduction strategies:[1]
In patients who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy ≥1 month post-PCI is useful to reduce bleeding risk (COR 1, LOE A).
In patients at high risk of gastrointestinal bleeding, a proton pump inhibitor is recommended in combination with DAPT (COR 1, LOE A).
De-escalation of DAPT (switching from ticagrelor or prasugrel to clopidogrel) after 1 month may be reasonable to reduce bleeding risk (COR 2b, LOE B-R).
In patients who require long-term oral anticoagulation, aspirin should be discontinued after 1 to 4 weeks of triple antithrombotic therapy, with continued use of a P2Y12 inhibitor (preferably clopidogrel) and an oral anticoagulant (COR 1, LOE B-R).
Secondary Prevention
The 2025 ACC/AHA guideline recommends:[1]
High-intensity statin therapy for all patients with ACS, with the option to initiate concurrent ezetimibe.
A nonstatin lipid-lowering agent (e.g., ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid) is recommended for patients already on maximally tolerated statin who have an LDL-C level of ≥70 mg/dL (1.8 mmol/L).
Special Populations
Cardiogenic Shock
Cardiogenic shock occurs in approximately 10% of patients with STEMI and is associated with an early mortality rate of 40% to 50%.[1]
Emergency revascularization of the culprit vessel by PCI or CABG is indicated irrespective of time from symptom onset (COR 1, LOE B-R).[1]
In selected patients with STEMI and severe or refractory cardiogenic shock, insertion of a microaxial intravascular flow pump (e.g., Impella) is reasonable to reduce death (COR 2a, LOE B-R). The DanGer Shock trial demonstrated that early use of a microaxial flow pump in select patients with STEMI-related shock improved 180-day survival with an absolute mortality reduction of 12.7%.[11]
Routine use of intra-aortic balloon pump (IABP) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) is not recommended due to a lack of survival benefit (COR 3: No Benefit, LOE B-R).[1]
Routine PCI of a noninfarct-related artery at the time of PPCI should not be performed in patients with cardiogenic shock (COR 3: Harm, LOE B-R).[1]
Late Presenters (12-24 Hours)
In patients with STEMI presenting 12 to 24 hours after symptom onset, PPCI is reasonable to improve clinical outcomes (COR 2a, LOE B-NR). The benefit of PPCI begins to diminish for those >12 hours from symptom onset, but there appears to be continued benefit through approximately 24 hours.[1]
Patients With Contraindications to Fibrinolytic Therapy
In patients with STEMI and a contraindication to fibrinolytic therapy who present to a non-PCI-capable hospital, transfer for PPCI is recommended regardless of anticipated transfer time (COR 1, LOE A).[1]
Patients Requiring Oral Anticoagulation
In patients with ACS who require oral anticoagulant therapy (e.g., for atrial fibrillation), aspirin should be discontinued after 1 to 4 weeks of triple antithrombotic therapy, with continued use of a P2Y12 inhibitor (preferably clopidogrel) and an oral anticoagulant to reduce bleeding risk (COR 1, LOE B-R).[1]
Evidence for Door-to-Balloon Time and Outcomes
Prognostic Impact of D2B Time
Park et al. (2019) analyzed 5,243 patients with STEMI treated at 20 tertiary hospitals. In multivariable analysis, D2B time showed an independent association with 1-year mortality (adjusted hazard ratio 1.90 per 1-hour delay; 95% CI 1.51-2.39; P<0.001). Reducing D2B time to within 45 minutes showed further decreased risk of mortality compared with D2B time >90 minutes (adjusted HR 0.30; 95% CI 0.19-0.42; P<0.001). Every reduction of D2B time by 30 minutes showed continuous reduction of 1-year mortality.[12]
Zahler et al. (2019) retrospectively studied 889 STEMI patients who underwent successful primary PCI with D2B ≤90 minutes. D2B <60 minutes was independently associated with a 51% risk reduction for 1-year mortality (OR 0.49; 95% CI 0.25-0.93; P=0.03).[13]
Total Ischemic Time Versus Door-to-Balloon Time
While D2B time has been the primary quality metric for STEMI care, growing evidence supports the importance of total ischemic time (symptom onset to reperfusion) as the most clinically meaningful determinant of outcomes. Shiomi et al. (2012) analyzed 3,391 patients with STEMI who underwent primary PCI within 24 hours of symptom onset across 26 tertiary hospitals in Japan. Short onset-to-balloon time (<3 hours) was independently associated with a lower risk of the composite of death and congestive heart failure (adjusted hazard ratio 0.70; 95% CI 0.56-0.88; P=0.002). However, the benefit of short D2B time (≤90 minutes) was limited to patients who presented early (within 2 hours of symptom onset; adjusted hazard ratio 0.58; 95% CI 0.38-0.87; P=0.009), with no significant benefit in patients with delayed presentation (interaction P=0.01).[14]
These findings underscore the importance of reducing patient-related delay (onset-to-door time) through public education campaigns, in addition to optimizing system-related delay (D2B time).
National Registry Data
Jollis et al. (2022) analyzed 114,871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines–Coronary Artery Disease registry between 2018 and 2021. Key findings included:[15]
| Presentation Mode | Median Symptom Onset-to-PCI Time | Key Mortality Finding |
|---|---|---|
| EMS to PCI-capable hospital | 148 minutes (IQR 111-226) | FMC-to-device ≤90 min: in-hospital mortality 3.3% vs 12.1% (adjusted OR 0.40; 95% CI 0.36-0.44) |
| Walk-in to PCI-capable hospital | 195 minutes (IQR 127-349) | Hospital arrival-to-device ≤90 min: in-hospital mortality 1.8% vs 4.7% (adjusted OR 0.47; 95% CI 0.40-0.55) |
| Transfer from non-PCI-capable hospital | 240 minutes (IQR 166-402) | First hospital arrival-to-device ≤120 min: in-hospital mortality 4.3% vs 14.2% (adjusted OR 0.44; 95% CI 0.26-0.71) |
System goals were not met in most quarters, with the most delayed system performance among patients requiring interhospital transfer (only 17% treated within ≤120 minutes).[15]
Complications
Ischemic and Bleeding Events After Primary PCI
Patients with STEMI undergoing primary PCI are at high risk for both ischemic and bleeding events. In the HORIZONS-AMI trial, the average daily rates for both adverse ischemic and bleeding events were highest early after the procedure and then dramatically declined over time. In the first 30 days, the absolute rates of bleeding exceeded those of ischemia and were influenced by the type of intraprocedural anticoagulation. Beyond 30 days, the absolute risk for ischemia exceeded the risk for bleeding.[16]
These findings support the use of bleeding avoidance strategies in the acute and subacute phases (e.g., radial artery access, bivalirudin) and potent antiplatelet therapy continuing through at least 1 year to prevent ischemic events, especially in patients without excessive bleeding risk.[16]
Stent Thrombosis
Stent thrombosis is a rare but potentially catastrophic complication of primary PCI. Risk factors include premature discontinuation of dual antiplatelet therapy, stent underexpansion, residual dissection, and high thrombus burden. Acute stent thrombosis (within 24 hours) may be influenced by the choice of intraprocedural anticoagulation, with bivalirudin associated with a slightly higher rate of acute stent thrombosis compared with unfractionated heparin plus glycoprotein IIb/IIIa inhibitors, although this risk may be mitigated by a post-procedural bivalirudin infusion at the PCI dose (1.75 mg/kg/h) for 3 to 4 hours.[16]
Coronary No-Reflow
No-reflow occurs in approximately 4% of patients undergoing primary PCI and is associated with larger infarct size and increased long-term mortality. The primary mechanism is microvascular obstruction, with contributing factors including ischemia/reperfusion injury, distal thromboembolization, endothelial dysfunction, and microvascular spasm. No therapy has been found to consistently prevent or reverse no-reflow, although intracoronary vasodilators (e.g., adenosine, nitroprusside, verapamil) may be considered.[4]
Quality Improvement and Performance Metrics
Mission: Lifeline Performance Measures
The AHA Mission: Lifeline program and the 2021 AHA Policy Statement on Systems of Care for STEMI recommend the following performance benchmarks:[6]
| Performance Measure | Target |
|---|---|
| Proportion of patients with FMC-to-device time ≤90 minutes (direct presentation to PCI-capable hospital) | ≥75% |
| Proportion of patients with FMC-to-device time ≤120 minutes (transfer patients) | ≥75% |
| Door-in-door-out (DIDO) time at referring hospital | ≤30 minutes |
| STEMI receiving center arrival-to-device time for transfer patients | ≤30 minutes (goal); strive for ≤60 minutes overall |
| Prehospital ECG acquisition rate | Maximize |
| Prehospital catheterization laboratory activation rate | Maximize |
| False-positive catheterization laboratory activation rate | Monitor; do not discourage activation |
Key Quality Improvement Strategies
The 2021 AHA Policy Statement and the 2025 ACC/AHA guideline recommend the following quality improvement strategies:[6][1]
Data collection and feedback: Robust mechanisms for data collection at every stage of care, with regular review meetings at local and system levels to drive process improvement.
Multidisciplinary team engagement: STEMI receiving centers should take the lead on coordinating multidisciplinary care and engaging STEMI referring hospitals, interhospital transport agencies, and EMS.
Prearranged transfer agreements: One-call transfer process, automatic acceptance, treatment algorithms, and primary and backup transfer processes should be established.
Community education: Educating the public on the need to immediately call 9-1-1 for ischemic symptoms and not drive themselves to the nearest hospital.
EMS training: Comprehensive training in ECG acquisition and interpretation, initial stabilization, prehospital notification, minimization of on-scene time, and determination of optimal transport destination.
Monitoring of false-positive activations: Thresholds for EMS activation without intervention should be established so that EMS is not discouraged from calling their findings because of negative feedback.
Impact of COVID-19 on STEMI Systems
Recent declines have been reported in the rates of achieving established STEMI performance measures, in part due to the COVID-19 pandemic and related challenges in ensuring adequate resourcing and staffing of EMS agencies and hospitals. All communities should continue to establish, reinvigorate, and maintain regional systems of STEMI care.[1]
Prehospital ECG and Catheterization Laboratory Activation
The early acquisition and recording of prehospital 12-lead ECGs by trained personnel is associated with shorter reperfusion times and lower mortality rates from STEMI. Appropriately trained EMS personnel (i.e., paramedics) can interpret 12-lead ECGs for the identification of STEMI with high accuracy.[1]
Three basic methods are recommended for interpretation of the prehospital ECG:[6]
Computer algorithm interpretation Trained paramedic interpretation Transmission for physician or advanced practice professional interpretation Prehospital catheterization laboratory activation has been associated with lower short- and long-term mortality in patients presenting with STEMI. Implementation of prehospital activation, single-call transfer protocols, and ED bypass to transport patients directly to the catheterization laboratory are recommended care processes to reduce reperfusion times.[1]
Prognosis
Prognosis in STEMI is strongly influenced by the timeliness of reperfusion, infarct size, left ventricular ejection fraction, and the presence of complications such as cardiogenic shock, heart failure, or ventricular arrhythmia.
In-hospital mortality for STEMI patients treated with primary PCI within guideline-recommended time targets ranges from approximately 1.8% to 4.3%, depending on the mode of presentation.[15]
In-hospital mortality increases substantially when time targets are not met, ranging from 4.7% to 14.2%.[15]
Every 30-minute reduction in D2B time is associated with a continuous reduction in 1-year mortality.[12]
D2B time <60 minutes has been independently associated with a 51% risk reduction for 1-year mortality compared with D2B time of 60-90 minutes.[13]
Total ischemic time is the most important time-based predictor of mortality, followed by system delay and D2B time.[17]
Summary
| Component | Key Recommendation | Source |
|---|---|---|
| Reperfusion strategy | Primary PCI preferred over fibrinolytic therapy when achievable within time targets | 2025 ACC/AHA Guideline |
| FMC-to-device time (direct) | ≤90 minutes | 2025 ACC/AHA Guideline |
| FMC-to-device time (transfer) | ≤120 minutes | 2025 ACC/AHA Guideline |
| DIDO time | ≤30 minutes | 2025 ACC/AHA Guideline |
| Prehospital ECG | Acquire and interpret within 10 minutes of FMC | 2025 ACC/AHA Guideline |
| Catheterization laboratory activation | Prehospital activation recommended | 2025 ACC/AHA Guideline |
| Vascular access | Radial artery access preferred | 2025 ACC/AHA Guideline |
| Anticoagulation | UFH or bivalirudin at time of PCI | 2025 ACC/AHA Guideline |
| Multivessel disease | Complete revascularization recommended | 2025 ACC/AHA Guideline |
| DAPT duration | ≥12 months (standard); shorter durations with P2Y12 monotherapy may be considered | 2025 ACC/AHA Guideline |
| Fibrinolysis (when PCI unavailable) | Administer within 30 minutes of hospital arrival; transfer for angiography within 2-24 hours | 2025 ACC/AHA Guideline |
| Cardiogenic shock | Emergency culprit vessel revascularization; consider mechanical circulatory support | 2025 ACC/AHA Guideline |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 Rao SV, O'Donoghue ML, Ruel M, et al. (2025). "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes". J Am Coll Cardiol. doi:10.1016/j.jacc.2024.11.009. PMID 36170841 Check
|pmid=value (help). - ↑ 2.0 2.1 Bhatt DL, Lopes RD, Harrington RA (2022-02-15). "Diagnosis and Treatment of Acute Coronary Syndromes: A Review". JAMA. 327 (7): 662–675. doi:10.1001/jama.2022.0358. PMID 35132876 Check
|pmid=value (help). - ↑ Menees DS, Peterson ED, Wang Y, et al. (2013-09-05). "Door-to-Balloon Time and Mortality Among Patients Undergoing Primary PCI". N Engl J Med. 369 (10): 901–909. doi:10.1056/NEJMoa1208200. PMID 24002794.
- ↑ 4.0 4.1 Ndrepepa G, Kastrati A (2023-08-27). "Coronary No-Reflow After Primary Percutaneous Coronary Intervention-Current Knowledge on Pathophysiology, Diagnosis, Clinical Impact and Therapy". J Clin Med. 12 (17): 5592. doi:10.3390/jcm12175592. PMID 37685660 Check
|pmid=value (help). - ↑ 5.0 5.1 Tamis-Holland JE, Abbott JD, Al-Azizi K, et al. (2024-11-01). "SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI". J Soc Cardiovasc Angiogr Interv.
- ↑ 6.0 6.1 6.2 6.3 6.4 Jacobs AK, Ali MJ, Best PJ, et al. (2021-11-16). "Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association". Circulation. 144 (24): e411–e430. doi:10.1161/CIR.0000000000001025.
- ↑ Bradley EH, Herrin J, Wang Y, et al. (2006-11-30). "Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction". N Engl J Med. 355 (22): 2308–2320. doi:10.1056/NEJMsa063117. PMID 17124018.
- ↑ O'Gara PT, Kushner FG, Ascheim DD, et al. (2013-01-29). "2013 ACCF/AHA Guideline for the Management of ST-elevation Myocardial Infarction: Executive Summary". J Am Coll Cardiol. 61 (4): 485–510. doi:10.1016/j.jacc.2012.11.019. PMID 23247304.
- ↑ Mehta SR, Wood DA, Storey RF, et al. (2019). "Complete Revascularization with Multivessel PCI for Myocardial Infarction". N Engl J Med. 381 (15): 1411–1421. doi:10.1056/NEJMoa1907775. PMID 31475799.
- ↑ Stähli BE, Varbella F, Linke A, et al. (2023-10-12). "Timing of Complete Revascularization With Multivessel PCI for Myocardial Infarction". N Engl J Med. 389 (15): 1368–1379. doi:10.1056/NEJMoa2307862. PMID 37634149 Check
|pmid=value (help). - ↑ Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO (2025-04-29). "2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock". J Am Coll Cardiol. doi:10.1016/j.jacc.2025.02.034.
- ↑ 12.0 12.1 Park J, Choi KH, Lee JM, et al. (2019-05-07). "Prognostic Implications of Door-to-Balloon Time and Onset-to-Door Time on Mortality in Patients With ST-Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention". J Am Heart Assoc. 8 (9): e012188. doi:10.1161/JAHA.119.012188. PMID 31041869.
- ↑ 13.0 13.1 {{cite journal |vauthors=Zahler D, Lee-Rozenfeld K, Ravid D, et al |title=Relation of Lowering Door-to-Balloon Time and Mortality in ST Segment Elevation Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention |journal=Clin Res Cardiol |volume=108 |issue=9 |pages=1013-1019 |date=2019-09 |pmid=30778668 |doi=10.1007/s00392-019-01437
- ↑ Shiomi H, Nakagawa Y, Morimoto T, et al. (2012-05-23). "Association of Onset to Balloon and Door to Balloon Time With Long Term Clinical Outcome in Patients With ST Elevation Acute Myocardial Infarction Having Primary Percutaneous Coronary Intervention: Observational Study". BMJ. 344: e3257. doi:10.1136/bmj.e3257. PMID 22623632.
- ↑ 15.0 15.1 15.2 15.3 Jollis JG, Granger CB, Zègre-Hemsey JK, et al. (2022-11-22). "Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021". JAMA. 328 (20): 2033–2043. doi:10.1001/jama.2022.20164. PMID 36413242 Check
|pmid=value (help). - ↑ 16.0 16.1 16.2 Giustino G, Mehran R, Dangas GD, et al. (2017-10-10). "Characterization of the Average Daily Ischemic and Bleeding Risk After Primary PCI for STEMI". J Am Coll Cardiol. 70 (15): 1872–1882. doi:10.1016/j.jacc.2017.08.018. PMID 28838364.
- ↑ Rafizadeh O, Erfani S, Zarbafti S, Erfani S (2026-05-01). "The Effects of Delays at Each Stage of Care on Mortality in Patients With ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention". Coron Artery Dis. PMID 41133776 Check
|pmid=value (help).