Door-to-balloon time targets in STEMI — when is fibrinolysis preferred over primary PCI?

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Per ACC/AHA 2013 STEMI guidelines, primary PCI is the preferred reperfusion strategy if door-to-balloon (D2B) time is ≤90 min (or ≤120 min from first medical contact). Fibrinolysis is preferred when: (1) PCI is unavailable at the presenting facility, AND (2) expected D2B time exceeds 120 minutes from first medical contact. Before administering alteplase, check the following absolute contraindications: - Any prior intracranial hemorrhage - Known structural cerebrovascular lesion (AVM) - Ischemic stroke within 3 months - Active internal bleeding (not menses) - Suspected aortic dissection - Significant closed-head/facial trauma within 3 months - Intracranial/intraspinal surgery within 2 months - Severe uncontrolled hypertension unresponsive to therapy Key relative contraindications: BP >180/110, INR >2, active peptic ulcer, pregnancy, prior non-hemorrhagic stroke >3 months ago. Regarding post-lysis transfer: YES — all patients who receive fibrinolysis should be transferred to a PCI-capable center regardless of apparent clinical reperfusion. Current guidelines recommend coronary angiography within 3–24 hours of successful fibrinolysis (pharmacoinvasive strategy). If fibrinolysis fails (less than 50% ST resolution at 60–90 min, persistent pain, hemodynamic instability), immediate rescue PCI is indicated.