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Time to reperfusion and door-to-balloon times are key parameters in assessing the efficiency of the primary PCI pathway while also being powerful predictors of outcome. This chapter discusses the role of these measures and how improvements may impact clinical outcomes.

In the context of ST-segment elevation myocardial infarction (STEMI), early and successful myocardial reperfusion by primary percutaneous coronary intervention (PPCI) is the most powerful intervention for reducing myocardial infarct (MI) size, preserving left ventricular (LV) systolic function and preventing the onset of heart failure. However, despite continual improvements in acute care, the mortality and morbidity rates following STEMI remain significant, with 7% death and 22% rehospitalisation for heart failure, at 1 year. Although timely reperfusion of the occluded vessel by PPCI is essential to minimise the acute ischaemic time (a major determinant of MI size) and salvage viable myocardium, the process of reperfusion itself, paradoxically, induces additional myocardial injury and cardiomyocyte death, a phenomenon which has been termed ‘myocardial reperfusion injury’. This has been shown to contribute to up to 50% of the final MI size, making it an important therapeutic target to reduce MI size in STEMI patients reperfused by PPCI. However, the translation of novel cardioprotective strategies for targeting myocardial reperfusion injury to reduce MI size following STEMI has been both challenging and disappointing. In this chapter, we provide an overview of myocardial reperfusion injury, discuss the challenges facing the investigation of treatment strategies for reducing MI size following STEMI and highlight future cardioprotective therapies for potentially improving clinical outcomes in STEMI patients.

Patients with ST-segment elevation myocardial infarction (STEMI) constitute a high-risk group who benefit significantly from established community and regional plans aimed at achieving coronary artery reperfusion at the earliest possible time. Public awareness of the symptoms of a heart attack, the presence of rapid response teams to transport and treat STEMI patients, and appropriate hospital facilities are essential components of this effort. Routine patient and health system data collection and analysis and comparison of risk-adjusted outcomes are required to ensure that physician and system performances are comparable to regional and national norms and to permit corrective action where needed. Enhanced regional efforts have been shown to improve treatment times and outcomes with a significant reduction in in-hospital mortality in STEMI patients treated with PCI.