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The 2012 European Society of Cardiology (ESC) ST-Elevation Myocardial Infarction (STEMI) guideline acknowledges that STEMI patients should receive reperfusion therapy as soon as possible, and that prehospital fibrinolysis or field-triage directly to Primary Percutaneous Coronary Intervention (PPCI) centres is the preferred reperfusion strategy.1 However, when recommending fibrinolytic therapy (FT) within 30 min from First Medical Contact (FMC), if PPCI cannot be performed ‘within 60 min of FMC in patients presenting early, with a large amount of myocardium at risk’, the guidelines imply that only 30 min extra may be expended to perform PPCI instead of administering FT (‘PCI-related delay’) (figure 1).
Throughout the years, successive guidelines have mistakenly equated ‘PCI-related delay’ and ‘FMC to PPCI’ (the total delay from FMC to PPCI) (figure 1). This error persists in the recently updated ESC guideline.1 Clarification of this distinction is of paramount importance because of the suggested reduction in the ‘window of opportunity for PPCI’, a suggestion not clearly supported by evidence, which has significant public health implications. In paragraph 3.5.2, the ESC STEMI guideline references a registry analysis from the National Registry of Myocardial Infarction (NRMI),2 concluding: ‘primary PCI (wire passage) should be performed within 90 min after FMC in all cases. In patients presenting early, with a large amount of myocardium at risk, the delay should be shorter (<60 min).’ The NRMI …
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