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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e804

primary endpoint of mortality at 30 days, emergency revascularization with either PCI or CABG surgery reduced mortality at 6 months,9 and the mortality rate benefit was maintained through 1 and 6 years.26,27 In an observational analysis from the FITT- STEMI (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction) trial, for every 10-minute delay in PPCI after 60 minutes from FMC, there were an additional 3 to 4 deaths per 100 with >80% mortality beyond 6 hours of delay from FMC for patients with cardiogenic shock.8 Therefore, it is recommended that PPCI should be performed in patients with STEMI and cardiogenic shock as soon as possible, ideally within 90 minutes, to reduce the mortality rate. Observational studies suggest that emergency CABG surgery remains a treatment option in patients with cardiogenic shock who are not amenable to primary reperfusion with PCI10,11 or when PCI is not successful.11,28

3 The benefit of PCI for asymptomatic patients pre-

senting 12 to 24 hours after symptom onset is not well studied. Small randomized trials of patients 12 to 48 hours after symptom onset in STEMI have demonstrated that PPCI reduces infarct size and improves the LVEF.12,14 These findings are further supported by observational data.13,15

4 No dedicated trials have been done that examine the

benefit of PPCI in patients with STEMI presenting late >24 hours after symptom onset who have clinical evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmias. Observational data and small trials suggest that PCI in patients with STEMI with delayed presentations is reasonable and is associated with improved outcomes.12,14,15

5 PCI is not recommended for an occluded infarct-

related artery if the patient is asymptomatic and has a completed infarct. MACE outcomes were similar in those with an occluded infarct-related artery versus those who underwent PCI 3 to 28 days after an MI (Occluded Artery Trial [OAT])16 and results were no different at 7 years follow-up.29 Similar findings were noted in the DECOPI (Desobstruction Coronaire en Post-Infarctus) trial, which enrolled patients with an occluded artery and Q waves on the ECG presenting 2 to 15 days after symptom onset.17

5.2.2 Urgent CABG Surgery

Recommendation for Urgent CABG Surgery Referenced studies that support recommendation are summarized in the Evidence Table.

COR LOE Recommendation

2a B-NR 1 In patients with STEMI in whom PCI is not feasible

or successful, with a large area of myocardium at risk, emergency or urgent CABG surgery can be effective to improve clinical outcomes.*1,2

*Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”3 Synopsis

Trials that evaluated the efficacy and safety of CABG surgery in STEMI are limited.4 When PCI is not possible for anatomic reasons or in the presence of complex disease, CABG surgery can be performed as the primary reperfusion strategy. After successful reperfusion of the infarct-related artery, CABG surgery can also be important when managing patients with more extensive noninfarct-related artery disease (Section 7.4.1, “Management of Multivessel CAD in STEMI”). The appropriate timing of CABG surgery in patients with STEMI should be determined on an individual basis, taking into consideration the hemodynamic stability of the patient, the presence of ongoing ischemia, and extent of myocardium at risk. After failed PPCI, emergency CABG surgery is not recommended in the absence of a large area of myocardium at risk or if surgical targets are poor and if surgery may be associated with an increased risk of death and adverse cardiovascular outcomes compared with nonsurgical management.5 For recommendations regarding CABG surgery in patients presenting with cardiogenic shock or mechanical complications, please refer to Section 8.1, “Revascularization in ACS With Cardiogenic Shock” and Section 9.1, “Mechanical Complications.”

Recommendation-Specific Supportive Text

1 No RCTs have been done that compare PPCI with

surgical revascularization in the setting of STEMI. For patients with STEMI who are hemodynamically stable with anatomy of the infarct-related artery that is not amenable to PPCI, or if PPCI is unsuccessful, CABG surgery can be useful if there is a large area of myocardium at risk. In such patients, particularly in the presence of ongoing ischemia or if a large area of myocardium is at risk, CABG surgery may be effectively performed as a primary reperfusion strategy or after PPCI.1,2 Despite an increase in the acuity of presentation and the burden of comorbidities, the in-hospital mortality rate after CABG surgery in patients with STEMI continues to decrease.1,4

5.3 Reperfusion at Non–PCI-Capable Hospitals

Recommendations for Reperfusion at Non–PCI-Capable Hospitals Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 A 1 In patients with STEMI and an estimated time

from FMC to device activation of ≤120 minutes or those with a contraindication to fibrinolytic therapy, transfer to a PCI-capable hospital for PPCI is recommended to reduce MACE.1–3

1 A 2 In patients with STEMI and symptom onset

of <12 hours and anticipated delay to PPCI >120 minutes from FMC, fibrinolytic therapy should be administered in patients without contraindication to reduce MACE.4–10

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