Enoxaparin and fondaparinux have been studied less extensively in this set- ting. The ATOLL (Acute STEMI Treated with Primary PCI and IV Enoxaparin or UFH to Lower Ischemic and Bleeding Events at Short- and Long-term Follow-up) trial comparing intravenous enoxaparin with UFH for primary PCI failed to meet its primary, composite endpoint.305 Fondaparinux has been associated with catheter thrombosis in this set- On the basis of the findings in the HORIZONS- O Gara et al 2013 ACCF/AHA STEMI Guideline e379 AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial,248 the writing committee considers bivalirudin, in combination with oral DAPT, a reasonable anticoagulant alternative for primary PCI in STEMI, regardless of whether pretreatment was given with UFH, especially for patients at higher risk of bleeding and when avoidance of GP IIb/IIIa antagonists is desired. Bivali- rudin in this setting may provide a long-term survival benefit related to decreased bleeding but with a higher risk of early 5. Reperfusion at a Non PCI-Capable Hospital 5.1. Fibrinolytic Therapy When There Is an Anticipated Delay to Performing Primary PCI Within 120 Minutes of FMC: Recommendations See Table 4 for a summary of recommendations from this section. Class I 1. In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previ- ous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of (Level of Evidence: A) Class IIa 1. In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability. (Level of Evidence: C) Class III: Harm 1. 