In a working diagnosis of ST-elevation myocardial infarction — persistent ST-segment elevation or equivalents with ischaemic symptoms of ≤12 hours duration — primary percutaneous coronary intervention (PPCI) within 120 minutes of diagnosis is the recommended first strategy. When that intervention does not achieve successful reperfusion, a further escalation step is required.
Primary percutaneous coronary intervention (PCI) — immediate angiography and PCI of the infarct-related artery within 120 minutes of diagnosis, with concomitant antithrombotic therapy — is the first-line approach. Escalation to this next step is indicated when the reperfusion goals of that strategy are not met: failure to achieve ≥50% ST-segment resolution on the electrocardiogram, persistence of ischaemic symptoms, or haemodynamic instability.
When primary PCI has not restored adequate perfusion, the evidence-based next step centres on emergency surgical intervention targeting the infarct-related artery. The complete indication criteria, patient selection considerations, and procedural details are available in the full structured protocol.
DOI: 10.1093/eurheartj/ehad191
Reperfusion therapy is recommended in all patients with a working diagnosis of STEMI (persistent ST-segment elevation or equivalents) and symptoms of ischaemia of ≤12 h duration.
A PPCI strategy is recommended over fibrinolysis if the anticipated time from diagnosis to PCI is <120 min.
Emergency coronary artery bypass grafting (CABG) surgery should be considered for patients with a patent IRA but with unsuitable anatomy for PCI, and either a large myocardial area at jeopardy or with CS.
In the setting of STEMI, CABG should be considered only when PPCI is not feasible, particularly in the presence of ongoing ischaemia or large areas of jeopardized myocardium.
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