.Is it better for an MI patient who needs percutaneous coronary intervention (PCI) to have fibrinolytic therapy at a nearby hospital or to go to a larger hospital 20 miles away that offers PCI?
—Leroy Schaffner, MD, Henrietta, Tex.

It depends on several factors, but the goal of either strategy is to keep the total ischemic time to 60 minutes, then fibrinolysis at the closest facility is preferred in the absence of contraindications. Transportation time will vary depending on time of day and traffic and will need to be considered in the triage decision for patients presenting beyond this “golden hour.” Emergent cardiac catheterization is preferred for the high-risk patient (i.e., exhibiting cardiogenic shock and Killip class >3). The patient in cardiogenic shock should be transported to a facility with skilled PCI as quickly as possible for revascularization and intra-aortic balloon pump (IABP) support. If transportation time is excessive, consideration should be given to fibrinolysis if a nearby facility has the ability to place an IABP, followed by subsequent transfer to a PCI-capable facility. For further information, see J Am Coll Cardiol. 2004;44:671-719.
—Norma M. Keller, MD (102-12)

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