New STEMI Guidelines: How Long Should We Wait for the Balloon?

Amal Mattu, MD


January 30, 2013


Consider the following scenario:

A 50-year-old man comes to your emergency department at 11:00 PM to visit his mother, a patient in your care. Suddenly he develops substernal chest pressure radiating bilaterally across his chest. He is diaphoretic, tachycardic, dyspneic, and vomiting. Your staff quickly places him in a monitored bed and obtains an ECG, which shows ST-segment tombstone-elevation in the anterior leads with reciprocal ST-segment depression in the inferior leads. You've made the diagnosis of ST-segment myocardial infarction (STEMI) within 5 minutes of symptom onset.

You then quickly explain to the patient the need for emergent reperfusion therapy. There are 2 choices: immediate administration of fibrinolytics (he has no contraindications) or emergent percutaneous coronary intervention (PCI). Given the late hour, the PCI team will need time to mobilize, but the interventional cardiologist reassures you that the patient can expect balloon inflation within 90 minutes, the national standard for time to balloon inflation in cases of STEMI. Which form of emergent reperfusion would you choose?

We've all learned that if balloon inflation can be achieved within 90 minutes, then PCI is preferential to fibrinolytics, but is that true in this case? Immediate administration of fibrinolytics to a patient so early in the course of his STEMI might very well abort the infarction. The alternative choice is to let this patient continue to infarct for the next 90 minutes before balloon inflation. Is it really appropriate for us to use 90 minutes as a single, "one size fits all" time limit for deciding when to choose PCI over fibrinolytics? The question is even more important now with the publication of the new 2013 Guidelines for Management of STEMI.

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
O'Gara PT, Kushner FG, Ascheim DD, et al
Circulation. 2012 Dec 17. [Epub ahead of print]

Study Summary

The American College of Cardiology (ACC) and the American Heart Association (AHA) last addressed the STEMI management guidelines in 2009 with a focused update of their 2004 guidelines.[1] The 2013 guidelines have provided some important new additions (eg, post-cardiac arrest care, use of new antiplatelet medications) and revisions to the prior guidelines. These should be considered must-reads for emergency physicians. A full review of the guidelines is beyond the scope of this discussion, but what is most relevant and a most notable change in the 2013 guidelines for this discussion is the extension of the 90-minute window to 120 minutes. In other words, the ACC/AHA now favors PCI over fibrinolytics with an even longer delay to balloon inflation than previously recommended. The guidelines clearly endorse an even more liberal use of PCI over fibrinolytics for STEMI despite the longer delays.