A speedy response and early recognition of AMI by general practitioners and ambulance services are of great importance, mainly for two reasons. First, mortality in the very early hours is substantial, and many patients die before adequate medical help has been sought and delivered (7). Second, although the results of primary PCI therapy are less time dependent than the results of thrombolysis (8), in particular during the first few hours, time is muscle. This is not only so from a theoretical perspective, but has been confirmed in a recent study that showed that an increase in time delay from presentation to first balloon inflation results in worse clinical outcome, in particular in high-risk patients (9). Confirmation of the diagnosis of AMI by 12-lead electrocardiography (EKG), by either general practitioners or ambulance paramedics, allows a substantial reduction of the time delay to first balloon inflation, because the hospital and the catheterization laboratory can be prepared in advance, and the emergency room and the cardiac care unit (CCU) (with their unavoidable delays) can be skipped on the way to acute angiography. Furthermore, it gives important opportunity to start initial pharmacologic therapy and use the transportation time in this regard. A primary PCI center must therefore develop additional specific training programs for general practitioners and ambulance services. Excellent communication with these first-line providers of care for patients with AMI is of paramount importance, because this will be among the main factors determining time to therapy.

If a definitive diagnosis has not been made before arrival at the hospital, it is very important that additional delays are avoided. A limited history and physical examination should be performed, and a 12-lead EKG should be made and interpreted within 5 to 10 minutes (7). Blood tests may be drawn, but results should not be waited on; a chest x-ray is
unnecessary. The first responsibility of the emergency room physician is to contact the catheterization laboratory and to get the patient there as soon as possible. Important organizational issues that determine the logistics in this regard are:

It is a great advantage if:

Finally, a flexible attitude shared by the catheterization laboratory staff and interventional cardiologist is a prerequisite. They should be prepared to change their program at a moment’s notice—drop a nice elective case planned for intracoronary ultrasound or multiple stenting—get out of bed in the middle of the night, and do this job as quickly and proficiently as they can.

Adequate pain relief and supplemental oxygen are essential, not only for humanitarian reasons, but in particular because the patient has to endure angiography and angioplasty (7). Aspirin should be given, at least 300 mg soluble chewable, but because gastrointestinal symptoms are frequent, it may be preferable to give 500 mg of aspirin intravenously. Sublingual and intravenous nitroglycerine as well as intravenous β-blockers (10), unless contraindicated, should be given in an effort to lower oxygen consumption and alleviate myocardial ischemia. Intravenous heparin can be used in an attempt to increase initial patency rates of the infarct-related vessel (11), and heparin plays an important role during the PCI. Abciximab and tirofiban as pretreatment and concomitant therapy can be recommended for most patients (12, 13, 14). Clopidogrel now is used in all patients with an acute coronary syndrome, and it should be started with a loading dose of at least 300 mg (15).