In this JAMA Cardiology viewpoint, Drs. Paul Armstrong, Kevin Bainey, and Christopher Granger argue that total ischemic time—the interval from symptom onset to the restoration of blood flow—is the most critical factor in surviving a severe heart attack, known as an ST-elevation myocardial infarction (STEMI). While the gold standard treatment is percutaneous coronary intervention (PCI), its life-saving capacity is crucially dependent on timely performance speed.
The authors highlight a critical gap in care: although STEMI guidelines recommend a 120-minute window from first medical contact to PCI, patients transferred from community hospitals often face much longer waits. The inability to achieve these targets is associated with a significant increase in adverse outcomes. Real-world data indicates that exceeding the 120-minute window is linked to an escalation in in-hospital mortality from 4.3% to 14.2%.
Consequently, the authors contend that when a 90-minute delay is anticipated, a pharmacoinvasive strategy—administering fibrinolysis (clot-dissolving medication) immediately before transfer—is the superior, preferred choice. They assert that the slight risk of intracranial hemorrhage is far outweighed by the significant mortality benefit of avoiding treatment delays.
The authors recommend that current STEMI care guidelines deserve to be updated to reflect modern advances achieved with pharmacoinvasive therapy; these include dose reduction in older patients, concomitant antiplatelet and antithrombotic therapy, and timely transfer to a PCI-capable facility for angiography and rescue capabilities. Rather than accepting prolonged transport delays, medical systems should prioritize myocardial salvage by targeting a 10–30 minute window for fibrinolysis and a 60–90 minute window for PCI from the point of first contact. This shift ensures that saving heart muscle remains the absolute priority, regardless of a patient’s geographic location.
