Background-Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior tofibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results-We

ESPITE ITS LIMITATIONS, THEstandard 12-lead electrocardiogram (ECG) remains a key diagnostic tool directing the emergency management of patients with an acute myocardial infarction. 1 In 1980, DeWood et al 2 reported that patients presenting with acute chest pain, persistent ST-segment elevation progressing to Q waves, and elevations of cardiac biomarker levels were found to have a total thrombotic coronary occlusion in 87% of cases. A variety of other serious conditions aside from an acute myocardial infarction may also cause ST-segment elevation. 3 Time to reperfusion is a major determinant of outcome in patients presenting with an ST-segment elevation myocardial infarction (STEMI). 4,5 The American College of Cardiology/ American Heart Association STEMI guidelines recommend that the emergency department physician make the decision regarding reperfusion therapy within 10 minutes of interpreting the initial diagnostic ECG, 6 which may be challenging because clinical decisions are often made without a previous ECG result for comparison or time to observe evolutionary ST-segment changes or cardiac biomarker results. Upstream activation of the cardiac cath-For editorial comment see p 2790.

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