Commentary: The Role of Percutaneous Coronary Intervention in ST-Segment–Elevation Myocardial Infarction

this issue of Circulation, Dr Gregg Stone offers a thorough review of percutaneous coronary intervention (PCI) strategies to treat ST-segment-elevation myocardial infarction (STEMI). 1,2 All of the major topics are addressed and comprehensively referenced, and the figures provide a concise summary of much of the evidence base. His ultimate vision is the establishment of STEMI systems of care dedicated to primary PCI. Improving patient outcomes in STEMI is a critical goal, and we agree that continued efforts are needed to expand prehospital and hospital-based emergency medical systems for STEMI patients. However, we also continue to believe that there are currently substantial challenges to delivering primary PCI rapidly and reliably in real-world settings. Given that some of the opinions offered by Stone differ from recommendations made by professional societies, we offer a different perspective on this controversial subject and provide some of the background thinking that led to the development of the 2004 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Patients With STelevation Myocardial Infarction 3 and the subsequent 2007 focused update. Our discussion also is informed by the ACC Door-to-Balloon (D2B) Alliance campaign 5 and the AHA Mission: Lifeline initiative. Our goal is not to debate the points made by Stone but to place PCI for STEMI in the broader context of the patient and the healthcare system. We do this by providing additional insights into the development of PCI strategies in STEMI, examining the critical challenges that remain for delivering primary PCI, highlighting the difference between fibrinolytic therapy and a fibrinolytic strategy, and endorsing a new paradigm for reperfusion therapy.