ST-Segment Elevation or New or Presumably New LBBB: Evaluation for Reperfusion

Step 1: Assess time and risk
Time since onset of symptoms
Risk of STEMI
Risk of fibrinolysis
Time required to transport to skilled PCI catheterization suite
Step 2: Select reperfusion (fibrinolysis or invasive) strategy
Note: If presentation <3 hours and no delay for PCI, then no preference for either strategy.
Fibrinolysis is generally preferred if:

  • Early presentation (≤3 hours from symptom onset)

  • Invasive strategy is not an option (eg, lack of access to skilled PCI facility or difficult vascular access) or would be delayed
    • – Medical contact-to-balloon or door-balloon >90 minutes

    • – (Door-to-balloon) minus (door-to-needle) is >1 hour

  • No contraindications to fibrinolysis

An invasive strategy is generally preferred if:

  • Late presentation (symptom onset >3 hours ago)

  • Skilled PCI facility available with surgical backup

  • Medical contact-to-balloon or door-to-balloon <90 minutes

  • (Door-to-balloon) minus (door-to-needle) is <1 hour

  • Contraindications to fibrinolysis, including increased risk of bleeding and ICH

  • High risk from STEMI (CHF, Killip class is ≥3)

  • Diagnosis of STEMI is in doubt

  • Modified from ACC/AHA 2004 Update Recommendations.1


  1. Division of Data Services. New Asthma Estimates: Tracking Prevalence, Health Care, and Mortality. Hyattsville, Md: National Center for Health Statistics; 2001.