Recommendations

48
Smith et al. 2005
ACC/AHA/SCAI Practice Guidelines
ACC - www.acc.org
AHA - www.americanheart.org
SCAI - www.scai.org
(378)
(415)
Figure 8. Comparison of elapsed time to fibrinolysis versus primary PCI. Time is presented as a continuous variable in minutes on
the horizontal axis. For DANAMI-2, times reflect components of delay from symptom onset to randomization (vertical bar) and are
further separated according to whether patients presented at community referral hospitals or those equipped for primary PCI. For
those patients randomized to PCI at a referral hospital, the 3 components of delay after randomization are related to duration of stay
at referral hospital, time for transport to PCI hospital, and delay from arrival at PCI hospital to balloon inflation. Lysis indicates fibrinolysis;
PCI, percutaneous coronary intervention; Rand, randomization; SK, streptokinase; and Transp, transportation. Top graph
reprinted with permission from Anderson et al. N Engl J Med 2003;349:733-42 (378). Copyright 2003 Massachusetts Medical Society.
All rights reserved. Bottom graph reprinted from Widimsky et al. Eur Heart J 2003;24:94-104 (415) with permission from the
European Society of Cardiology.
33% relative risk reduction with primary PCI compared with
a 9% relative risk reduction with fibrinolytic therapy (447-
449). Primary PCI in patients with anterior STEMI reduces
mortality compared with fibrinolytic therapy, but there is no
difference in patients with nonanterior STEMI (450,451).
Despite the evidence supporting primary PCI in the treatment
of STEMI, there is serious concern that a routine policy
of primary PCI for patients with STEMI will result in
unacceptable delays in achieving reperfusion in a substantial
number of patients and less than optimal outcomes if performed
by less experienced operators. The mean time delay
for PCI instead of fibrinolysis in the randomized trials was
only 40 min (364). Strict performance criteria must be mandated
for primary angioplasty programs so that excessive
delays in reperfusion and performance by low-volume or
poor-outcome operators/centers do not occur. The physicians,
nursing, and technical catheterization laboratory staff
must be experienced in handling acutely ill patients, must be
skilled in all aspects of interventional equipment and procedures,
and must participate in a 24-hours-per-day, 365-daysper-year
call schedule. Interventional cardiologists and centers
should strive for 1) balloon dilation within 90 min of
admission and diagnosis of STEMI (452); 2) TIMI 2 to 3
flow attained in more than 90% of patients; 3) emergency
CABG rate less than 2% among all patients undergoing the
procedure; 4) actual performance of PCI in 85% of patients
brought to the laboratory; and 5) a risk-adjusted in-hospital
mortality rate less than 7% in patients without cardiogenic