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’†, 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 all. In a 22 481 patient US registry, for instance, only 43% of transferred STEMI patients with estimated drive times exceeding 30 min achieved a first-contact-to-balloon delay below 120 min, while only half of the patients with a drive time >60 min received fibrinolysis.4 These inherent system delays when transferring patients are certainly not trivial, as they appear to have the highest negative impact on mortality, significantly more than treatment and patient-related delays.5