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Figure 1 Options for Transportation of STEMI Patients and Initial Reperfusion Treatment Goals

Reperfusion in patients with STEMI can be accomplished by pharmacological (fibrinolysis) or catheter-based (primary PCI) approaches. The overarching goal is to keep total ischemic time within 120 min (ideally within 60 min) from symptom onset to initiation of reperfusion treatment. Within this context, the following are goals for the medical system based on the mode of patient transportation and the capabilities of the receiving hospital. The medical system goal is to facilitate rapid recognition and treatment of patients with STEMI so that door-to-needle (or medical contact-to-needle) for initiation of fibrinolytic therapy can be achieved within 30 min or door-to-balloon (or medical contact-to-balloon) for PCI can be achieved within 90 min. These goals should not be understood as "ideal" times but rather the longest times that should be considered acceptable for a given system. Systems that are able to achieve even more rapid times for treatment of patients with STEMI should be encouraged. Medical system goals: EMS transport (recommended): 1. If EMS has fibrinolytic capability and the patient qualifies for therapy, pre-hospital fibrinolysis should be started within 30 min of arrival of EMS on the scene; 2. If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a non–PCI-capable hospital, the door-to-needle time should be within 30 min for patients for whom fibrinolysis is indicated; 3. If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a PCI-capable hospital, the EMS arrival-to-balloon time should be within 90 min; 4. If EMS takes the patient to a non–PCI-capable hospital, it is appropriate to consider emergency interhospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if: there is a contraindication to fibrinolysis; PCI can be initiated promptly within 90 min from EMS arrival-to-balloon time at the PCI-capable hospital*; or fibrinolysis is administered and is unsuccessful (i.e., "rescue PCI"). Patient self-transport (discouraged): 1. If the patient arrives at a non–PCI-capable hospital, the door-to-needle time should be within 30 min of arrival at the emergency department; 2. If the patient arrives at a PCI-capable hospital, the door-to-balloon time should be within 90 min; 3. If the patient presents to a non–PCI-capable hospital, it is appropriate to consider emergency interhospital transfer of the patient to a PCI-capable hospital if: there is a contraindication to fibrinolysis; PCI can be initiated within 90 min after the patient presented to the initial receiving hospital or within 60 min compared with when fibrinolysis with a fibrin-specific agent could be initiated at the initial receiving hospital; or fibrinolysis is administered and is unsuccessful (i.e., "rescue PCI"). Note that "medical contact" is defined as "time of EMS arrival on scene" after the patient calls EMS/911 or "time of arrival at the emergency department door" (whether PCI-capable or non–PCI-capable hospital) when the patient transports himself/herself to the hospital. Source: Figure 1 in Antman et al. (26). *EMS ArrivalTransport to non–PCI-capable hospitalArrival at non–PCI-capable hospital to transfer to PCI-capable hospitalArrival at PCI-capable hospital-to-balloon time = 90 min. EMS = emergency medical system; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.