1.Time required for transport to skilled PCI lab: door-to-balloon <120 min & [door-to-balloon]–[door-to-needle] <1 h favors transfer for PCI
2.Risk from STEMI: high-risk Pts (eg, shock) fare better with mechanical reperfusion
3.Time to presentation: efficacy of lytics ↓ w/ ↑ time from sx onset, espec >3 h
4.Risk of fibrinolysis: if high risk of ICH or bleeding, PCI safer option
Adapted from ACC/AHA 2013 STEMI Guidelines (Circ 2013;127:529)
Fibrinolysis
- Indic: STE/LBBB + sx <12 h (& >120 min before PCI can be done); benefit if sx >12 h less clear; reasonable if persist. sx & STE, hemodynamic instability or large territory at risk
- Mortality ↓ ~20% in anterior MI or LBBB and ~10% in IMI c/w Ø reperfusion Rx
- Prehospital lysis (ie, ambulance): further 17% ↓ in mortality (JAMA 2000;283:2686)
- ~1% risk of ICH; high risk incl elderly (~2% if >75 y), ♀, low wt. ? PCI more attractive