Is There Any Time Left for Primary Percutaneous Coronary Intervention According to the 2007 Updated American College of Cardiology/American Heart Association ST-Segment Elevation Myocardial Infarction Guidelines and the D2B Alliance?

Early reperfusion therapy is essential in the treatment of patients with ST-segment elevation myocardial infarction. Fibrinolytic therapy is a feasible reperfusion strategy to be initiated at any hospital and preferably in the pre-hospital phase. Primary percutaneous coronary intervention (PPCI) is acknowledged as a superior reperfusion strategy when initiated in a timely fashion. It is also the preferred reperfusion therapy in patients who exhibit cardiogenic shock and in patients with contraindications to fibrinolysis. However, in many regions, it is difficult to establish a successful PPCI strategy because it mandates optimal pre-hospital and in-hospital triage to ensure acceptable treatment delays. The 2007 updated American College of Cardiology/American Heart Association ST-Segment Elevation Myocardial Infarction Guidelines stress that “the focus for PPCI is from first medical contact because in regionalization strategies, extra time may be taken to transport patients to a center that performs the procedure” and that “time from Emergency Medical Services arrival to balloon inflation should be <90 minutes.” When considering fibrinolysis, however, the guidelines accept a door-to-needle time of 30 min from arrival at the local hospital. Is there evidence to justify that, in the PPCI setting, the clock starts ticking upon the arrival of the Emergency Medical Services but, in the setting of in-hospital fibrinolysis, it does not start until a patient's arrival at the local hospital?