The AHA Guidelines and Scientific Statements Handbook

Chapter 3 ST-Elevation Myocardial Infarction

Primary PCI without on-site cardiac surgery

Class IIb
Primary PCI might be considered in hospitals
without on-site cardiac surgery, provided that there
exists a proven plan for rapid transport to a cardiac
surgery operating room in a nearby hospital with
appropriate hemodynamic support capability for
transfer. The procedure should be limited to patients
with STEMI or MI with new, or presumably new,
LBBB on ECG, and should be done in a timely
fashion (balloon infl ation within 90 minutes of pre-
sentation) by persons skilled in the procedure (at
least 75 PCIs per year) and at hospitals that perform
a minimum of 36 primary PCI procedures per year.
(Level of Evidence: B)

Class III
Primary PCI should not be performed in hospitals
without on-site cardiac surgery and without a proven
plan for rapid transport to a cardiac surgery operat-
ing room in a nearby hospital or without appropri-
ate hemodynamic support capability for transfer.
(Level of Evidence: C)

Facilitated PCI
See Figure 3.5 [14].

Class IIb

Facilitated PCI using regimens other than full-dose

fi brinolytic therapy might be considered as a reper-

fusion strategy when all of the following are present:

(a) patients are at high risk; (b) PCI is not immedi-

ately available within 90 minutes; and (c) bleeding

risk is low (younger age, absence of poorly con-

trolled hypertension, normal body weight). (Level of

Evidence: C)

Class III

A planned reperfusion strategy using full-dose fi bri-

nolytic therapy followed by PCI is not recommended

and may be harmful. (Level of Evidence: B)

Immediate (or emergency) invasive strategy and

rescue PCI See Table 3.3 [15].

Class I

A strategy of coronary angiography with intent to

perform PCI (or emergency CABG) is recommended

for patients who have received fi brinolytic therapy

and have any of the following: (a) cardiogenic shock

and age less than 75 years and are suitable candidates

Fig. 3.5 Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction. The results of
three pharmacologic reperfusion strategies (lytic alone, GP IIb/IIIa inhibitor alone, or a combination of lytic + GP IIb/IIIa inhibitor) are
compared with primary percutaneous coronary intervention (PPCI) for patients with STEMI. Data are shown for mortality, reinfarction, and
major bleeding. Adapted from data in Keeley et al., Lancet. 2006;367:579.