Primary percutaneous coronary intervention for acute myocardial infarction: Is it worth the wait?: The risk-time relationship and the need to quantify the impact of delay

The efficacy of reperfusion therapy is dependent not only by the duration of symptoms before therapy but also by the baseline risk of the individual and the circumstances (time and context) of the occurrence. All these variables play a crucial role in determining the choice of best therapy (fibrinolysis or primary angioplasty [primary percutaneous coronary intervention, PPCI]), thereby confirming the admonition that one size does not fit all. It is generally accepted that patients are best served by PPCI when times to therapy are equal between PPCI and fibrinolysis, whereas pivotal issues that are less well supported by evidence include whether a single time interval is appropriate with regard to the "acceptable" PPCI-related delay and what degree of transfer-related delay is acceptable in patients presenting "early" to a non-percutaneous coronary intervention (PCI)-capable facility. The aim of this perspective is to use available data to individualize the approach to reperfusion therapy, taking into account temporal delays and the overall mortality risk on a case-by-case basis.