Editorial 420I n the past 2 decades, we have seen dramatic changes in the care of patients with ST-elevation-myocardial infarction (STEMI). Randomized, controlled trials in the early 1990s showed that primary percutaneous coronary intervention (PCI) was superior to fibrinolytic therapy, and a 2003 meta-analysis of 23 clinical trials firmly established primary PCI as the preferred treatment for STEMI patients.1 However, studies also showed that the effectiveness of primary PCI decreased if there was a substantial time delay.2 A metaregression analysis by Nallamothu et al 3 showed that the comparative advantage of primary PCI over fibrinolytic therapy was lost if the added procedural and logistical complexity of primary PCI resulted in more than a 60-minute time delay in reperfusion. On the basis of this analysis, a 90-minute door-to-balloon time goal was established, and the 2004 American College of Cardiology/American Heart Association (ACC/AHA) STEMI guideline writers challenged caregivers by recommending that STEMI patients presenting to a facility where PCI could not be administered within 90 minutes of first contract should receive fibrinolytic therapy instead of primary PCI. Articles see p 423, 429, 437The use of primary PCI steadily increased, yet a 2002 study showed that only about a third of patients who received primary PCI for STEMI had a door-to-balloon time of less than 90 minutes.5 Some hospitals succeeded in improving door-toballoon times, and research by Bradley et al 6,7 identified strategies that were associated with consistently better results. These strategies became the focus of D2B: An Alliance for Quality, a national campaign sponsored by the ACC and 26 other organizations, including the AHA.8 Starting in 2006, the D2B Alliance recruited more than 1000 hospitals nationwide, with a goal of achieving a door-to-balloon time of less than 90 minutes in more than 75% of patients. Door-toballoon times began to improve dramatically, and, by 2010, 91% of patients receiving primary PCI in the United States had a door-to-balloon time of less than 90 minutes. 9,10The D2B Alliance addressed the timeliness of primary PCI for patients presenting to a PCI hospital, but not all hospitals are PCI-capable. How should we treat patients with STEMI who present to non-PCI hospitals? Randomized, controlled trials have shown that transferring patients for primary PCI is more effective than fibrinolytic therapy, but it remains unclear whether these results coming from specialized centers can be reproduced in practice and how much transfer delay is acceptable.11 In 2004, the transfer times from non-PCI hospitals to PCI-capable hospitals remained unacceptably high, with only about 4% of transferred patients having a first door-toballoon time of less than 90 minutes.12 A more recent study showed that the time to transfer a STEMI patient from a non-PCI hospital (the door-in-door-out time) was 68 minutes, and prolonged times were associated with higher in-hospital mortality. 13To address these broader issues, the 2007 F...