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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e803

pandemic and related challenges in ensuring adequate resourcing and staffing of EMS agencies and hospitals. Therefore, all communities should continue to establish, reinvigorate, and maintain regional systems of STEMI care to improve outcomes of patients with STEMI globally. The collection of high-quality data at every stage of care is an inseparable component of a STEMI system of care. Successful STEMI systems have robust mechanisms for (1) educating the public of the need to immediately call 9-1-1 (or other appropriate local emergency services) for ischemic symptoms and not driving themselves to the nearest hospital; (2) data collection that balances the need for adequate data capture without introducing data overburden; (3) data sharing within hospital departments (eg, ED and cardiology) or between hospitals and EMS agencies; and (4) meetings to review and discuss shared data at local and system levels to drive process improvement.

5.2 Reperfusion at PCI-Capable Hospitals

5.2.1 PPCI in STEMI

Recommendations for PPCI in STEMI Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 A 1 In patients with STEMI presenting <12 hours

after symptom onset, PPCI should be performed with a goal of FMC to device activation of ≤90 minutes, or ≤120 minutes in patients requiring hospital transfer, to improve survival.1–7

1 B-R 2 In patients with ACS and cardiogenic shock or

hemodynamic instability, emergency revascularization of the culprit vessel by PCI or CABG is indicated to improve survival, irrespective of time from symptom onset.8–11

2a B-NR 3 In patients with STEMI presenting 12 to 24 hours

after symptom onset, PPCI is reasonable to improve clinical outcomes.*12–15

2a C-LD 4 In patients with STEMI presenting >24 hours after

symptom onset with the presence of ongoing ischemia or life-threatening arrhythmia, PPCI is reasonable to improve clinical outcomes.†12,14

3: No Benefit B-R 5 In patients who are stable with STEMI who have

a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit.†16,17

*Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”18

Synopsis Timely PPCI confers improved survival compared with fibrinolytic therapy as primary reperfusion therapy for patients with STEMI.6,7 Systems of care designed to reduce the time to PPCI for patients with STEMI have been consequential in reducing risk of early death.19,20 The goal is to provide PPCI as soon as possible after the diagnosis of STEMI is made with first device activation within 90 minutes from FMC among walk-in and EMS-transported patients and 120 minutes for transfer patients from non–PCI-capable facilities.1–7 The benefit of PPCI begins to diminish for those >12 hours from symptom onset, but there appears to be continued benefit for PPCI through approximately 24 hours.12,13 In stable asymptomatic patients with an occluded artery >48 hours after symptom onset, routine PCI has not been shown to be beneficial in the absence of ongoing ischemia; the relative utility of routine PCI for asymptomatic patients with STEMI between 24 to 48 hours from symptom onset is less rigorously tested.14,15 However, coronary revascularization should be considered for patients with late presentations with continued signs and symptoms of ischemia, including cardiogenic shock, acute severe HF, persistent angina, and life-threatening arrhythmias.

Recommendation-Specific Supportive Text

1 PPCI is the recommended reperfusion therapy in

patients with STEMI and ischemic symptoms when performed ≤90 minutes (FMC–to–first-device activation) or ≤120 minutes in transfer patients to improve survival.1–7 The success of PPCI in achieving these goals was facilitated by the introduction in 2006 of the AHA’s Mission: Lifeline programs involving EMS and clinicians (eg, emergency medicine, cardiology, nursing) with practiced drill-down programs and regionalization of care21 that have improved myocardial salvage, as well as reduced risk of death and adverse outcomes.4,22,23 PPCI is superior to fibrinolytic therapy, which is used when the patient is in a non–PCI-capable hospital and transfer time to a PCI-capable hospital is anticipated to be >120 minutes. Compared with fibrinolytic therapy with a similar treatment delay, PPCI offers higher rates of infarct-related artery patency, and restoring TIMI 3 epicardial flow grade, as well as lower rates of recurrent ischemia, reinfarction, emergency repeat revascularization procedures, intracranial hemorrhage, and death.6,7 Radial access for PPCI has further reduced death, decreased access site bleeding, decreased the need for transfusion, and reduced acute kidney injury when compared with femoral access (Section 7.1, “Vascular Access Approach for PCI”).24,25

2 In the SHOCK (Should We Emergently Revascularize

Occluded Coronaries for Cardiogenic Shock) trial,9 reported in 1999, patients with AMI and cardiogenic shock were randomized to medical therapy or emergency revascularization. Among the patients randomized to revascularization, 64% of patients were referred for PCI and 36% for CABG surgery. The median time from randomization to revascularization was 0.9 hours for PCI and 2.7 hours for CABG surgery. Despite lack of a significant difference in the

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