cardiovascular disorders
Revascularization for Acute Coronary Syndromes
ST Segment Elevation Myocardial Infarction
 90 minutes) by an experienced operator ( General reference ). Indications for urgent PCI later in the course of STEMI include hemodynamic instability, malignant arrhythmias requiring transvenous pacing or repeated cardioversion, and age If there is likely to be a significant delay in availability of PCI, thrombolysis should be done for STEMI patients meeting criteria (see table Fibrinolytic Therapy for STEMI ). Reperfusion using fibrinolytics is most effective if given in the first few minutes to hours after onset of myocardial infarction. The earlier a fibrinolytic is begun, the better. The goal is a door-to-needle time of 30 to 60 minutes. Greatest benefit occurs within 3 hours, but the drugs may be effective up to 12 hours. Used with Regardless, most patients who undergo thrombolysis will ultimately require transfer to a PCI-capable facility for elective angiography and PCI as necessary before discharge. PCI should be considered after fibrinolytics if chest pain or ST-segment elevation persists≥60 minutes after initiation of fibrinolytics or if pain and ST-segment elevation recur, but only if PCI can be initiated<90 minutes after onset of recurrence. If PCI is unavailable, fibrinolytics can be repeated. Characteristics and selection of Fibrinolytics are discussed elsewhere. 