A 62-year-old man with acute STEMI is being considered for reperfusion therapy. His symptom onset was 3 hours ago. Which single feature best distinguishes a patient suitable for primary percutaneous coronary intervention (PCI) from one who should receive fibrinolytic therapy?

## Primary PCI vs Fibrinolysis: The Key Discriminator **Key Point:** The **availability of a PCI-capable facility with achievable door-to-balloon time ≤90 minutes** is the single most important discriminator determining whether a STEMI patient should undergo primary PCI or receive fibrinolytic therapy. ### Reperfusion Strategy Selection Algorithm ```mermaid flowchart TD A[STEMI Diagnosis]:::outcome --> B{PCI-capable facility available?}:::decision B -->|Yes + DtB ≤90 min| C[Primary PCI]:::action B -->|No or DtB >90 min| D{Fibrinolytic eligible?}:::decision D -->|Yes| E[Fibrinolysis + Transfer for angiography]:::action D -->|No| F[Transfer for PCI]:::action C --> G[Reperfusion achieved]:::outcome E --> H[Reperfusion achieved]:::outcome F --> I[Reperfusion achieved]:::outcome ``` ### Comparison: PCI vs Fibrinolysis Selection Criteria | Criterion | Primary PCI | Fibrinolysis | | --- | --- | --- | | **Door-to-balloon time** | ≤90 minutes (preferred) | Not applicable | | **Door-to-needle time** | Not applicable | ≤30 minutes | | **Facility requirement** | PCI-capable laboratory | Any hospital | | **Time window** | Up to 12 hours (optimal <12 hrs) | Up to 12 hours (optimal <3 hrs) | | **Cardiogenic shock** | **Preferred** (superior outcomes) | Relative contraindication | | **Age >75 years** | Still preferred if DtB achievable | Relative contraindication | | **Contraindications** | Minimal | Multiple (bleeding risk, recent surgery) | **High-Yield:** Current guidelines (ACC/AHA 2017, ESC 2017) recommend **primary PCI as the preferred reperfusion strategy** IF the expected door-to-balloon time is ≤90 minutes from first medical contact. If this cannot be achieved, fibrinolysis should be administered without delay (door-to-needle ≤30 minutes). **Clinical Pearl:** In India, where many centers lack 24/7 PCI capability, the **"fibrinolysis-first" strategy with planned early angiography** (within 3–24 hours) is often the practical choice. However, the **discriminating principle remains**: if PCI can be done promptly (DtB ≤90 min), it is superior to fibrinolysis. **Warning:** ~~Time from symptom onset alone does not determine the choice of reperfusion strategy.~~ Both PCI and fibrinolysis are effective within the 12-hour window; the **infrastructure and logistics** (DtB vs DTN) determine the choice. **Mnemonic:** **DtB ≤90 = PCI; DTN ≤30 = Fibrinolysis** (Door-to-Balloon ≤90 minutes favors PCI; Door-to-Needle ≤30 minutes is the target for fibrinolysis).