Transporting STEMI patients for primary PCI: a long and winding road paved with good intentions?

This editorial refers to ‘Early ST elevation myocardial infarction in non-capable percutaneous coronary intervention centres: in situ fibrinolysis vs. percutaneous coronary intervention transfer’[†][1], by X. Carrillo et al ., on page 1034. Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion therapy for patients presenting with an ST-segment elevation myocardial infarction (STEMI).1 However, as the majority of hospitals worldwide do not have catheterization facilities, the performance of a pPCI within the appropriate time frames by an experienced interventional team is often far from straightforward. Indeed, pPCI comes with several logistic challenges: one needs a well-oiled pre-hospital network with a commonly agreed protocol, trained medical or paramedical transport personnel, and 24/7 expedite services. In contrast to pPCI, fibrinolytic therapy is universally available, does not require additional technical expertise, and can be administered via a bolus to eligible patients by (para)medical personnel in the pre-hospital setting. Especially in patients presenting early (i.e. <3 h) after symptom onset, pre-hospital fibrinolysis is an excellent alternative for patients who cannot undergo a pPCI within 1 h.2,3 Contemporary guidelines therefore explicitly list maximal tolerated transfer delays of 90 min, or even a maximal 60 min treatment delay in cases where the patient first presents directly to a PCI-capable hospital or when presenting within 2 h after symptom onset ( Figure 1 ).1 On aggregate, guidelines recommend using fibrinolysis given in the ambulance or on-site when the expected time from first medical contact (FMC) to start of PCI exceeds 120 min. Achieving these goals consistently in the majority of patients is challenging: recent real-world registries clearly show that both reperfusion strategies are not optimally used at … [1]: #fn-2