Version July 2025
AMI: acute myocardial infarction; ECG: electrocardiogram; ED: emergency department; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction.
* Refer to UpToDate content on selecting a reperfusion strategy in STEMI for more information on patients with late presentation.
¶ In patients in whom the duration of symptoms is unclear, the optimal approach to therapy should be determined using clinical judgement that incorporates the history provided, objective findings (eg, ECG changes), and risks and benefits of the options available for reperfusion.
Δ This time interval includes all time required for transfer and other aspects of care until balloon dilation, thrombectomy, or other definitive percutaneous intervention is performed.
◊ Clinical features that may favor PCI include unclear timing of symptom onset, ongoing cardiogenic shock, or other complications attributable to ischemia (eg, arrhythmias, heart failure). Fibrinolysis is rarely performed in patients who present more than 12 hours after symptom onset.
§ Refer to UpToDate content for details on the absolute and relative contraindications to fibrinolysis in patients with acute STEMI.
¥ The selection and use of a specific fibrinolytic agent and the associated anticoagulant and antiplatelet therapies are discussed in UpToDate topics on fibrinolysis in AMI.
‡ For patients who do not undergo PCI or fibrinolysis, refer to UpToDate content for a discussion of optimal medical management.