STEMI patient who is a candidate for reperfusion

<End Node 3>

<End Node 4>

Initially seen at a PCI-capable facility

Initially seen at a non-PCI-capable facility

Send to cath lab for primary PCI

Preparatory antithrombotic (anticoagulant plus antiplatelet) regimen

Diagnostic angiography

Diagnostic angiography

Medical therapy only

PCI with stent

CABG

End

End

End

Time since onset of symptoms
Risk of STEMI
Risk of fibrinolysis
Time required for transport to a skilled PCI lab

At PCI facility, evaluate for timing of diagnostic angio

HIGH RISK

Transfer to a PCI facility is reasonable for early diagnostic angio and possible PCI or CABG
High-risk patients as defined by 2007 STEMI focused update should undergo cath

NOT HIGH RISK

Transfer to a PCI facility may be considered especially if ischemic symptoms persist and failure to reperfuse is suspected

Selection of reperfusion strategy^*

Transfer for primary PCI

Initial treatment with fibrinolytic