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Late Presentation STEMI PCI Window — EECC MCQ

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ModerateCoronary Artery DiseaseLate Presentation STEMI PCI WindowEECC

A 62-year-old man presents 8 hours after onset of anterior STEMI. His chest pain has resolved and he has no ongoing ischaemia. ECG still shows ST elevation with Q waves in V1-V4. Should he still undergo primary PCI?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Primary PCI should still be considered — benefit is greatest within 12 hours of symptom onset; the 2023 ESC ACS Guidelines recommend primary PCI within 12 hours (Class I), and even at 12-48 hours for patients with ongoing symptoms, haemodynamic instability, or arrhythmias

The time window for primary PCI benefit extends to 12 hours from symptom onset (Class I, LOE A). Beyond 12 hours: (1) 12-48 hours with ongoing symptoms, haemodynamic instability, or arrhythmias: PCI recommended (Class I); (2) 12-48 hours, asymptomatic and stable: PCI may be considered (Class IIa — OAT trial data); (3) >48 hours, asymptomatic and stable with occluded artery: PCI is NOT recommended (Class III — OAT trial showed no benefit and potential harm). This patient at 8 hours is well within the Class I window. Q waves indicate some transmural necrosis but do NOT mean the entire territory is non-viable — significant myocardial salvage is possible even with Q waves, particularly at the border zone.

Reference: ESC (2023): ACS Guidelines