STEMI management

Total coronary occlusion requiring emergent reperfusion. Primary PCI is preferred; fibrinolysis when PCI cannot be achieved within 120 min. Every 10-minute delay in reperfusion increases mortality. The CCS 2019 framework centres on time targets from first medical contact (FMC) — CCS 2019.

reperfusion principles

achieve coronary patency in all patients presenting <12h from symptom onset or with ongoing symptoms
FMC = first medical contact (EMS arrival at scene, or hospital registration if walk-in)
FMC to STEMI diagnosis (ECG acquisition + interpretation): ≤10 minutes

reperfusion time targets

Metric	Target
FMC to ECG diagnosis	≤10 min
diagnosis to cath lab activation	≤10 min
door-in to door-out (non-PCI centre)	≤30 min
interfacility transport time	≤60 min
FMC to device — at PCI centre	≤90 min
FMC to device — transferred/field patients	≤120 min
FMC to fibrinolysis (needle time)	≤30 min
fibrinolysis to coronary angiography	<24 hours

primary PCI

PPCI > fibrinolysis when it can be rapidly performed
PCI-capable centre: target FMC-to-device ≤90 min
non-PCI centre or prehospital: target FMC-to-device ≤120 min including transfer
if ≤120 min cannot be achieved → fibrinolysis

procedural aspects

radial access preferred over femoral when performed by experienced operator — reduces bleeding, possibly mortality
routine thrombectomy NOT recommended — possible increased stroke risk; bailout thrombectomy may be useful for high residual thrombus burden
anticoagulation during PCI: UFH recommended; bivalirudin is alternative (preferred if HIT or very high bleed risk); fondaparinux NOT recommended for PPCI
GP IIb/IIIa inhibitors: not routinely recommended IV or IC; may be useful if no oral antiplatelet given or for residual thrombus/no-reflow
IC fibrinolysis / IC adenosine: not routine; may be considered selectively for large residual thrombus or no-reflow

multivessel disease in STEMI

haemodynamically stable + multivessel disease → complete revascularisation can be considered (at time of PPCI or staged)
cardiogenic shock + multivessel disease → culprit-only PCI — CULPRIT-SHOCK (2017) showed culprit-only PCI had lower mortality than immediate multivessel PCI
chronic total occlusions should NOT be treated during initial PPCI

fibrinolysis

Indicated when PCI cannot be achieved within 120 min of FMC and no contraindications.

target FMC-to-needle ≤30 min
greatest benefit within first 2–3 hours of symptom onset
can be given up to 12h after onset with ST elevation
fibrin-specific agents preferred (tenecteplase, reteplase, alteplase) — lower mortality
half-dose tenecteplase may be considered for patients >75 years
can be considered in STEMI + cardiogenic shock when excessive delays to cath lab anticipated

absolute contraindications — mnemonic: HABITS

Letter	Contraindication
H	haemorrhage — intracranial, ever
A	aortic dissection
B	bleeding (diathesis or active) and BP (>180/110 despite therapy)
I	intracranial (lesion, AVM, malignancy)
T	trauma (significant closed head within 3 months)
S	stroke (ischaemic within 3 months)

pharmacoinvasive strategy

Definition: fibrinolysis first, then routine rapid transfer to PCI centre.

routine rapid transfer to PCI centre after fibrinolysis
failed reperfusion (<50% ST resolution at 60–90 min, persistent pain/instability) → immediate rescue PCI
successful fibrinolysis → routine angiography ± PCI within 24 hours
alternative to PPCI for early presenters (<3h), low bleed risk, when rapid PPCI unavailable

facilitated PCI is harmful

Full-dose lysis given en route to immediate PCI is strongly recommended against (high-quality evidence). This is different from the pharmacoinvasive strategy, where fibrinolysis is the primary reperfusion and angiography follows within 24h.

prehospital management

prehospital ECG: EMS should acquire ECG in field to identify STEMI and alert care teams
bypass non-PCI centres: transport directly to nearest PPCI centre if FMC-to-device ≤120 min achievable
ED bypass: reasonable to transport directly to cath lab bypassing PCI centre ED
oxygen: avoid routine supplemental O₂ if SpO₂ ≥90% — hyperoxaemia may increase infarct size
opioids: avoid routine IV opioids — delays P2Y12 inhibitor absorption; selective use for severe pain acceptable
P2Y12 in ambulance: not routinely recommended for transport <60 min; give in ED or cath lab; may consider if transport >60 min or prehospital fibrinolysis

what NOT to do

facilitated PCI (full-dose lysis + immediate PCI)
routine thrombectomy during PPCI
multivessel PCI during initial PPCI in cardiogenic shock
fondaparinux as sole anticoagulant during PPCI
routine GP IIb/IIIa inhibitors
routine supplemental O₂ with SpO₂ ≥90%
routine IV opioids