STEMI — Reperfusion Strategy Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] STEMI confirmation & reperfusion decision
   STEMI confirmed and symptoms <12 h? (STEMI = ischemic symptoms + ECG ST-elevation (or new LBBB). Immediate supportive care (oxygen only if hypoxemic, nitrates, analgesia), dual antiplatelet therapy, anticoagulation, ECG monitoring with defibrillator ready; start the reperfusion decision on confirmation.)
   • Yes (symptoms <12 h) → Primary PCI achievable within 120 min?
   • No (symptoms >12 h) → Symptoms >12 h
2. [Decision] Primary PCI achievable within 120 min?
   Can primary PCI be done within 120 min of STEMI diagnosis? (Primary PCI is the preferred reperfusion. On-site cath lab door-to-balloon target ≤60 min; with transfer, FMC-to-device ≤90–120 min.)
   • Yes (≤120 min) → Primary PCI (preferred)
   • No (>120 min) → Thrombolysis + pharmaco-invasive strategy
3. [End] Primary PCI (preferred)
   Primary PCI: open the infarct-related artery as fast as possible (radial access preferred), door-to-balloon ≤60 min (≤90 with transfer). PCI is especially preferred with acute heart failure or cardiogenic shock, with mechanical circulatory support if needed. After PCI: dual antiplatelet + high-intensity statin + secondary prevention, monitor ≥24 h.
4. [End] Thrombolysis + pharmaco-invasive strategy
   Cannot reach PCI in time (>120 min): thrombolyse as soon as possible within 12 h if no contraindication, door-to-needle ≤10 min, preferably a weight-adjusted single bolus of tenecteplase (half-dose if ≥75 years to reduce intracranial hemorrhage). Transfer to a PCI center regardless of success, with angiography within 2–24 h (immediate rescue PCI if thrombolysis fails).
5. [End] Symptoms >12 h
   Symptoms >12 h: if ongoing ischemia, hemodynamic instability or life-threatening arrhythmia → primary PCI; routine primary PCI may be considered at 12–48 h. Completely asymptomatic, stable patients are assessed by a non-emergency strategy.

Source guidelines & references

• 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023 · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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