ACS / STEMI — Reperfusion Pathway
Source: ACC/AHA Guideline for Management of Acute Coronary Syndromes 2025 · Last reviewed: Jul 2026
12-lead ECG within 10 min of first medical contact. Aspirin loading (chewed), oxygen if SpO₂ <90%, nitrates/morphine per symptoms.
ST elevation meeting STEMI criteria?
No → NSTEMI/UA pathway (separate algorithm, not yet published). Yes → continue below.
Facility capable of primary PCI within target time?
Primary PCI
Target door-to-balloon ≤90 min (direct presentation) or ≤120 min (requires transfer).
DAPT: aspirin + ticagrelor/prasugrel (preferred over clopidogrel). Anticoagulant: UFH (or bivalirudin).
Fibrinolytic (if delay >120 min & onset <12 h)
Target door-to-needle ≤30 min, followed by transfer for angiography (pharmaco-invasive approach).
DAPT: aspirin + clopidogrel (mandatory on the fibrinolytic pathway). Anticoagulant: enoxaparin/fondaparinux.