Primary PCI Time Targets and Organizational Standards for STEMI Networks in Asia

Performance Time Targets

Primary PCI should be performed within 90 minutes of first medical contact (FMC) for patients presenting directly to PCI‑capable hospitals; an aspirational median door‑to‑balloon time of 60–70 minutes is recommended. (American College of Cardiology) 1
At least 75 % of all STEMI patients are expected to meet the 90‑minute FMC‑to‑balloon benchmark, acknowledging unavoidable clinical delays in a minority. (American College of Cardiology) 1
For patients requiring inter‑hospital transfer from non‑PCI‑capable facilities, the target FMC‑to‑balloon time is ≤120 minutes, with a goal of ≤90 minutes whenever feasible. (American Heart Association) 2

STEMI networks must formally designate PCI‑capable “receiving” hospitals and non‑PCI “referral” hospitals, and establish written transfer protocols. (American Heart Association) 3
PCI‑capable centers must perform ≥200 PCI procedures annually, including ≥36 primary PCIs for STEMI. (American Heart Association) 4
Individual interventional cardiologists should perform >75 PCI procedures per year, ideally ≥11 primary PCIs for STEMI annually. (American Heart Association) 2
Primary PCI capability must be available 24 hours a day, 7 days a week. (American College of Cardiology) 1
On‑site cardiac surgical backup is required for all PCI‑capable centers. (American Heart Association) 4

Emergency medical services (EMS) must be equipped with 12‑lead ECG capability and have authority to activate the catheterization laboratory directly, bypassing the emergency department when appropriate. (American College of Cardiology) 1
EMS personnel should transmit ECG findings to the receiving hospital to enable early cath‑lab activation. (American College of Cardiology) 5
When estimated transport time exceeds the PCI time targets, EMS should be able to administer pre‑hospital fibrinolytic therapy. (American College of Cardiology) 5
Direct‑to‑PCI‑center transport protocols for EMS‑identified STEMI patients are recommended. (American Heart Association) 6

If FMC‑to‑balloon time can be achieved ≤120 minutes, immediate transfer to a PCI‑capable hospital is the preferred strategy and fibrinolysis should be withheld. (American Heart Association) 6
When FMC‑to‑balloon time is projected >120 minutes, fibrinolytic therapy should be administered within 30 minutes of hospital arrival (door‑to‑needle ≤30 minutes). (American College of Cardiology) 1
For patients presenting <2 hours from symptom onset, if the expected door‑to‑balloon time exceeds the expected door‑to‑needle time by >1 hour, fibrinolysis is preferred even if transfer is possible. (American Heart Association) 4

STEMI networks should conduct continuous outcomes analysis and periodic case review to identify process improvements. (American College of Cardiology) 1
Regular multidisciplinary team meetings to review all STEMI cases, especially those exceeding time targets, are essential. (American College of Cardiology) 1
Transparent public reporting of institutional performance metrics (e.g., proportion of patients treated ≤90 minutes) drives accountability. (American College of Cardiology) 1
Performance should be measured using FMC‑to‑balloon time rather than door‑to‑balloon time alone, to capture the entire system’s efficiency. (American College of Cardiology) 5

Hospitals and operators that do not meet the minimum volume thresholds (≥200 total PCIs and ≥36 primary PCIs per year for hospitals; >75 PCIs per year for operators) should not perform primary PCI and should function as referral centers with fibrinolytic capability. (American Heart Association) 2
The clinical benefit of primary PCI has not been established in centers or operators below these volume thresholds. (American Heart Association) 2

The American College of Cardiology recommends that primary PCI should be performed with a goal of medical contact-to-balloon time within 90 minutes for patients presenting with STEMI who can undergo PCI of the infarct artery within 12 hours of symptom onset, which represents a Class I recommendation with Level of Evidence B 7, 8, 9, 10, 11
The 90-minute target is strongly recommended based on solid clinical evidence, with the goal of maximizing reperfusion benefits 7, 8, 9

For patients requiring interhospital transfer, the first medical contact-to-balloon time goal is extended to 120 minutes, recognizing the logistical challenges of transfer while maintaining emphasis on achieving times ≤90 minutes whenever possible 12

The ACC/AHA Task Force lowered the goal from 120 minutes to 90 minutes to maximize reperfusion benefits, based on evidence showing improved outcomes with faster treatment times 13

When symptom duration is <3 hours, primary PCI is generally preferred if the expected door-to-balloon time minus expected door-to-needle time is ≤1 hour, based on recommendations from the American College of Cardiology 7, 8, 9, 10, 11
When symptom duration is >3 hours, primary PCI is generally preferred and should be performed with medical contact-to-balloon time as brief as possible, with goal within 90 minutes, as recommended by the American College of Cardiology 7, 8, 9, 10, 11

The American College of Cardiology recommends that primary PCI should be performed by operators performing >75 PCI procedures per year, ideally ≥11 primary PCIs per year for STEMI 14, 15, 16
The procedure should be performed at centers performing >200 PCI procedures per year, of which ≥36 are primary PCI for STEMI, with cardiac surgery capability, as recommended by the American College of Cardiology 14, 7, 8, 9, 15, 10, 16, 11

For patients with cardiogenic shock, the American College of Cardiology recommends that patients <75 years old who develop shock within 36 hours of MI should undergo revascularization within 18 hours of shock onset 7, 8, 9, 10, 11
For patients with severe heart failure, medical contact-to-balloon time should be as short as possible with goal within 90 minutes when symptom onset is within 12 hours, as recommended by the American College of Cardiology 7, 8, 9, 10, 11

Hospitals unable to consistently meet the 90-minute (or 120-minute for transfers) time goals should use fibrinolytic therapy as their primary reperfusion strategy, according to the American College of Cardiology 12
The benefit of primary PCI is not well established when performed by operators doing <75 PCI procedures per year, as stated by the American College of Cardiology 7, 8, 9, 10, 11