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Timely and optimal treatment of patients with STEMI

Nature Reviews Cardiology volume 10, pages 41–48 (2013)Cite this article

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Abstract

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.

Key Points

  • In patients with ST-segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PPCI) should be performed within 120 min of first medical contact (FMC)

  • If FMC-to-PPCI delay is >120 min, fibrinolysis is recommended instead of PPCI in patients with STEMI, but this guideline overlooks the fact that fibrinolysis cannot be initiated instantaneously at FMC

  • PPCI is superior to fibrinolysis in reducing mortality if the 'PCI-related delay' is <120 min

  • The guidelines for the management of patients with STEMI should make a clear distinction between the recommended FMC-to-PPCI delay and the acceptable PCI-related delay

  • In places where FMC-to-PPCI delay is >120 min, PPCI might still be the optimal reperfusion strategy if the PCI-related delay is <120 min

  • In patients with STEMI, prehospital diagnosis is mandatory and should be combined with field triage directly to large-volume PPCI centres, bypassing local hospitals, coronary care units, and emergency departments

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Figure 1: Causes of delay to reperfusion.
Figure 2: Association between outcome and delay to reperfusion with fibrinolysis and PPCI in patients with ST-segment elevation myocardial infarction.
Figure 3: Association between FMC-to-PPCI delay and mortality in patients with ST-segment elevation myocardial infarction.
Figure 4: Relationship between PCI-related delay and in-hospital mortality.

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  1. Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej, Aarhus N, 8200, DK, Denmark

    Jens F. Lassen, Hans E. Bøtker & Christian J. Terkelsen

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H. E. Bøtker declares that he owns shares of stock in CellAegis. The other authors declare no competing interests.

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Lassen, J., Bøtker, H. & Terkelsen, C. Timely and optimal treatment of patients with STEMI. Nat Rev Cardiol 10, 41–48 (2013). https://doi.org/10.1038/nrcardio.2012.156

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