Primary percutaneous coronary intervention (PCI) remains the preferred reperfusion strategy for patients presenting with ST-elevation myocardial infarction (STEMI), provided it can be performed in a timely and appropriate setting. The 2025 ACC/AHA guidelines classify indications for primary PCI based on symptom duration, hemodynamic status, and ongoing ischemic risk. Understanding these classes helps clinicians make rapid, evidence-based decisions in acute coronary care.
CLASS I INDICATIONS (Procedure Recommended)
Primary PCI is strongly recommended when clear benefit outweighs risk.
STEMI with symptom onset less than 12 hours
Patients presenting within 12 hours of symptom onset derive the greatest mortality and morbidity benefit from immediate reperfusion. Primary PCI should be performed as soon as possible, ideally within guideline-recommended door-to-balloon times.
Acute coronary syndrome with cardiogenic shock or hemodynamic instability
In patients with STEMI or other ACS presentations complicated by cardiogenic shock or severe hemodynamic instability, primary PCI is indicated irrespective of the time since symptom onset. Revascularization in this setting improves survival and stabilizes end-organ perfusion.
CLASS IIa INDICATIONS (Procedure Reasonable)
Primary PCI is reasonable and generally favored when clinical features suggest ongoing benefit.
STEMI with symptom onset between 12 and 24 hours
Patients presenting late but within 24 hours of symptom onset may still benefit from primary PCI, particularly if there is evidence of ongoing myocardial jeopardy.
STEMI with symptom onset greater than 24 hours with high-risk features
Primary PCI can be considered beyond 24 hours if any of the following are present: – Ongoing or recurrent ischemia
– Heart failure attributable to ischemia
– Life-threatening ventricular arrhythmias
In these scenarios, revascularization may limit infarct extension, improve hemodynamics, and reduce arrhythmic risk.
CLASS III INDICATIONS (Procedure Not Recommended)
Primary PCI is not recommended when there is no expected clinical benefit.
STEMI with totally occluded infarct-related artery more than 24 hours after symptom onset in a stable, asymptomatic patient
Routine opening of an occluded artery in stable patients without symptoms or ischemia has not shown benefit and may expose patients to unnecessary procedural risk.
Clinical Perspective
Time to reperfusion remains a critical determinant of outcome in STEMI, but patient stability and ongoing ischemic risk are equally important in late presenters. While early primary PCI is life-saving, selected late-presenting patients may still benefit, whereas routine intervention in stable, asymptomatic patients beyond 24 hours should be avoided. Applying guideline-based class recommendations ensures optimal use of resources and improves patient outcomes.
Source: 2025 ACC/AHA Guidelines
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