Compared with fibrinolytic therapy in RCTs, primary PCI produces higher rates for infarct artery patency, TIMI flow grade 3, and Table 9. Indications for Coronary Angiography in STEMI Indications COR LOE References Immediate coronary angiography Candidate for primary PCI I A 351,379 382 Severe heart failure or cardiogenic shock (if suitable revascularization candidate) I B 383,384 Moderate to large area of myocardium at risk and evidence of failed fibrinolysis IIa B 385,386 Coronary angiography 3 to 24 h after fibrinolysis Hemodynamically stable patients with evidence for successful fibrinolysis IIa A 387 391 Coronary angiography before hospital discharge Stable patients IIb C N/A Coronary angiography at any time Patients in whom the risks of revascularization are likely to outweigh the benefits or the patient or designee does not want invasive care III: No Benefit C N/A COR indicates class of recommendation; LOE, level of evidence; N/A, not applicable; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. lower rates for recurrent ischemia, reinfarction, emergency repeat revascularization procedures, intracranial hemorrhage, and death.379 Early, successful PCI also greatly decreases the complications of STEMI that result from longer ischemic times or unsuccessful fibrinolytic therapy, allowing earlier hospital discharge and resumption of daily activities. The greatest mortality benefit of primary PCI is in high-risk patients. PCI outcomes may not be as successful with prolonged time-to-treatment or low-volume hospitals and operators (Table 10). Several reports have shown excellent outcomes for patients with STEMI undergoing interhospital transfer where first med- ical contact to-door balloon time modestly exceeded the sys- tematic goal of 90 minutes.396 398,409 In these reports, the referring hospital and the receiving hospital established a transfer protocol that minimized transfer delays, and out- comes were similar to those of direct-admission patients. 