View source for Emergent PCI protocols and door-to-balloon time management


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==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.<ref name="pmid36170841">{{cite journal |vauthors=Rao SV, O'Donoghue ML, Ruel M, et al |title=2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes |journal=J Am Coll Cardiol |volume= |issue= |pages= |date=2025 |pmid=36170841 |doi=10.1016/j.jacc.2024.11.009 |url=}}</ref>

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.<ref name="pmid36170841"/> 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%.<ref name="pmid35132876">{{cite journal |vauthors=Bhatt DL, Lopes RD, Harrington RA |title=Diagnosis and Treatment of Acute Coronary Syndromes: A Review |journal=JAMA |volume=327 |issue=7 |pages=662-675 |date=2022-02-15 |pmid=35132876 |doi=10.1001/jama.2022.0358 |url=}}</ref>

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.<ref name="pmid36170841"/> 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.<ref name="pmid24002794">{{cite journal |vauthors=Menees DS, Peterson ED, Wang Y, et al |title=Door-to-Balloon Time and Mortality Among Patients Undergoing Primary PCI |journal=N Engl J Med |volume=369 |issue=10 |pages=901-909 |date=2013-09-05 |pmid=24002794 |doi=10.1056/NEJMoa1208200 |url=}}</ref>

==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 phenomenon|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.<ref name="pmid37685660">{{cite journal |vauthors=Ndrepepa G, Kastrati A |title=Coronary No-Reflow After Primary Percutaneous Coronary Intervention-Current Knowledge on Pathophysiology, Diagnosis, Clinical Impact and Therapy |journal=J Clin Med |volume=12 |issue=17 |pages=5592 |date=2023-08-27 |pmid=37685660 |doi=10.3390/jcm12175592 |url=}}</ref> 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.<ref name="pmidSCAI2024">{{cite journal |vauthors=Tamis-Holland JE, Abbott JD, Al-Azizi K, et al |title=SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI |journal=J Soc Cardiovasc Angiogr Interv |volume= |issue= |pages= |date=2024-11-01 |pmid= |doi= |url=}}</ref>

==Time Metrics and Definitions==

Several time intervals are used to measure the efficiency of STEMI care systems:

{| class="wikitable"

|-

! 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):<ref name="pmid36170841"/>

{| class="wikitable"

|-

! 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 [[coronary artery bypass grafting|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).<ref name="pmid36170841"/> Fibrin-specific agents are preferred over non-fibrin-specific agents due to superior patency rates.<ref name="pmid36170841"/>

==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:<ref name="pmid36170841"/><ref name="pmidAHA2021">{{cite journal |vauthors=Jacobs AK, Ali MJ, Best PJ, et al |title=Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association |journal=Circulation |volume=144 |issue=24 |pages=e411-e430 |date=2021-11-16 |pmid= |doi=10.1161/CIR.0000000000001025 |url=}}</ref>

'''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:<ref name="pmid17124018">{{cite journal |vauthors=Bradley EH, Herrin J, Wang Y, et al |title=Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction |journal=N Engl J Med |volume=355 |issue=22 |pages=2308-2320 |date=2006-11-30 |pmid=17124018 |doi=10.1056/NEJMsa063117 |url=}}</ref>

{| class="wikitable"

|-

! 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.<ref name="pmidAHA2021"/>

===Transfer Protocols for Non-PCI-Capable Hospitals===

For patients presenting to a non-PCI-capable hospital:<ref name="pmid36170841"/>

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).<ref name="pmid36170841"/>

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):<ref name="pmid36170841"/>

[[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).<ref name="pmid36170841"/>

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:<ref name="pmid36170841"/><ref name="pmid23247304">{{cite journal |vauthors=O'Gara PT, Kushner FG, Ascheim DD, et al |title=2013 ACCF/AHA Guideline for the Management of ST-elevation Myocardial Infarction: Executive Summary |journal=J Am Coll Cardiol |volume=61 |issue=4 |pages=485-510 |date=2013-01-29 |pmid=23247304 |doi=10.1016/j.jacc.2012.11.019 |url=}}</ref>

{| class="wikitable"

|-

! 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).<ref name="pmid36170841"/> 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.<ref name="pmid36170841"/>

====Stent Selection====

[[Drug-eluting stent]]s are the standard of care for primary PCI in STEMI. [[Bare-metal stent]]s 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).<ref name="pmid36170841"/> 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.<ref name="pmid31475799">{{cite journal |vauthors=Mehta SR, Wood DA, Storey RF, et al |title=Complete Revascularization with Multivessel PCI for Myocardial Infarction |journal=N Engl J Med |volume=381 |issue=15 |pages=1411-1421 |date=2019 |pmid=31475799 |doi=10.1056/NEJMoa1907775 |url=}}</ref>

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.<ref name="pmid37634149">{{cite journal |vauthors=Stähli BE, Varbella F, Linke A, et al |title=Timing of Complete Revascularization With Multivessel PCI for Myocardial Infarction |journal=N Engl J Med |volume=389 |issue=15 |pages=1368-1379 |date=2023-10-12 |pmid=37634149 |doi=10.1056/NEJMoa2307862 |url=}}</ref>

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).<ref name="pmid36170841"/>

====Management of No-Reflow====

Prevention and early recognition are the foundations of no-reflow management. Strategies include:<ref name="pmidSCAI2024"/>

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:<ref name="pmid36170841"/>

{| class="wikitable"

|-

! 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.<ref name="pmid35132876"/>

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.<ref name="pmid36170841"/>

====Contraindications to Fibrinolytic Therapy====

{| class="wikitable"

|-

! 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

[[Dementia]]

Known intracranial pathology not covered in absolute contraindications

Traumatic or prolonged (>10 minutes) [[cardiopulmonary resuscitation|CPR]]

Major surgery (<3 weeks)

Recent (within 2 to 4 weeks) internal bleeding

Noncompressible vascular punctures

[[Pregnancy]]

Active [[peptic ulcer]]

Oral [[anticoagulant]] therapy

|}

====Coronary Angiography After Fibrinolytic Therapy====

All patients receiving fibrinolytic therapy should be transferred to a PCI-capable hospital:<ref name="pmid36170841"/>

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).<ref name="pmid36170841"/>

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:<ref name="pmid36170841"/>

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:<ref name="pmid36170841"/>

'''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 [[low-density lipoprotein|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%.<ref name="pmid36170841"/>

Emergency revascularization of the culprit vessel by PCI or CABG is indicated irrespective of time from symptom onset (COR 1, LOE B-R).<ref name="pmid36170841"/>

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%.<ref name="pmidACCCS2025">{{cite journal |vauthors=Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO |title=2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock |journal=J Am Coll Cardiol |volume= |issue= |pages= |date=2025-04-29 |pmid= |doi=10.1016/j.jacc.2025.02.034 |url=}}</ref>

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).<ref name="pmid36170841"/>

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).<ref name="pmid36170841"/>

====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.<ref name="pmid36170841"/>

====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).<ref name="pmid36170841"/>

====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).<ref name="pmid36170841"/>

==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.<ref name="pmid31041869">{{cite journal |vauthors=Park J, Choi KH, Lee JM, et al |title=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 |journal=J Am Heart Assoc |volume=8 |issue=9 |pages=e012188 |date=2019-05-07 |pmid=31041869 |doi=10.1161/JAHA.119.012188 |url=}}</ref>

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).<ref name="pmid30778668">{{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</ref>

===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).<ref name="pmid22623632">{{cite journal |vauthors=Shiomi H, Nakagawa Y, Morimoto T, et al |title=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 |journal=BMJ |volume=344 |issue= |pages=e3257 |date=2012-05-23 |pmid=22623632 |doi=10.1136/bmj.e3257 |url=}}</ref>

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:<ref name="pmid36413242">{{cite journal |vauthors=Jollis JG, Granger CB, Zègre-Hemsey JK, et al |title=Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021 |journal=JAMA |volume=328 |issue=20 |pages=2033-2043 |date=2022-11-22 |pmid=36413242 |doi=10.1001/jama.2022.20164 |url=}}</ref>

{| class="wikitable"

|-

! 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).<ref name="pmid36413242"/>

==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.<ref name="pmid28838364">{{cite journal |vauthors=Giustino G, Mehran R, Dangas GD, et al |title=Characterization of the Average Daily Ischemic and Bleeding Risk After Primary PCI for STEMI |journal=J Am Coll Cardiol |volume=70 |issue=15 |pages=1872-1882 |date=2017-10-10 |pmid=28838364 |doi=10.1016/j.jacc.2017.08.018 |url=}}</ref>

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.<ref name="pmid28838364"/>

===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 inhibitor]]s, 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.<ref name="pmid28838364"/>

===Coronary No-Reflow===

[[No-reflow phenomenon|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.<ref name="pmid37685660">{{cite journal |vauthors=Ndrepepa G, Kastrati A |title=Coronary No-Reflow After Primary Percutaneous Coronary Intervention-Current Knowledge on Pathophysiology, Diagnosis, Clinical Impact and Therapy |journal=J Clin Med |volume=12 |issue=17 |pages=5592 |date=2023-08-27 |pmid=37685660 |doi=10.3390/jcm12175592 |url=}}</ref>

==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:<ref name="pmidAHA2021">{{cite journal |vauthors=Jacobs AK, Ali MJ, Best PJ, et al |title=Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association |journal=Circulation |volume=144 |issue=24 |pages=e411-e430 |date=2021-11-16 |pmid= |doi=10.1161/CIR.0000000000001025 |url=}}</ref>

{| class="wikitable"

|-

! 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:<ref name="pmidAHA2021"/><ref name="pmid36170841">{{cite journal |vauthors=Rao SV, O'Donoghue ML, Ruel M, et al |title=2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes |journal=J Am Coll Cardiol |volume= |issue= |pages= |date=2025 |pmid=36170841 |doi=10.1016/j.jacc.2024.11.009 |url=}}</ref>

'''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.<ref name="pmid36170841"/>

==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.<ref name="pmid36170841"/>

Three basic methods are recommended for interpretation of the prehospital ECG:<ref name="pmidAHA2021"/>

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.<ref name="pmid36170841"/>

==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.<ref name="pmid36413242"/>

In-hospital mortality increases substantially when time targets are not met, ranging from 4.7% to 14.2%.<ref name="pmid36413242"/>

Every 30-minute reduction in D2B time is associated with a continuous reduction in 1-year mortality.<ref name="pmid31041869">{{cite journal |vauthors=Park J, Choi KH, Lee JM, et al |title=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 |journal=J Am Heart Assoc |volume=8 |issue=9 |pages=e012188 |date=2019-05-07 |pmid=31041869 |doi=10.1161/JAHA.119.012188 |url=}}</ref>

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.<ref name="pmid30778668">{{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/s00392-019-01437-7 |url=}}</ref>

Total ischemic time is the most important time-based predictor of mortality, followed by system delay and D2B time.<ref name="pmid41133776">{{cite journal |vauthors=Rafizadeh O, Erfani S, Zarbafti S, Erfani S |title=The Effects of Delays at Each Stage of Care on Mortality in Patients With ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention |journal=Coron Artery Dis |volume= |issue= |pages= |date=2026-05-01 |pmid=41133776 |doi= |url=}}</ref>

==Summary==

{| class="wikitable"

|-

! 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==

{{Reflist|2}}

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