O Gara et al 2013 ACCF/AHA STEMI Guideline e381 with impaired renal function.340 Fondaparinux should not be given as the sole anticoagulant to patients referred for PCI and is contraindicated for patients with a creatinine clearance <30 Bivalirudin may be used for patients treated with a fibrinolytic agent who develop HIT and require continued 5.2. Assessment of Reperfusion After Fibrinolysis TIMI 3 flow after fibrinolytic therapy predicts subsequent short- and long-term survival.343 345 Traditional variables that have been used to assess the angiographic response to fibrinolytic therapy are imprecise346 and have included an improvement in or relief of chest pain, resolution of ST elevation, and the pres- ence of reperfusion arrhythmias (eg, accelerated idioventricular rhythm). The relatively sudden and complete relief of chest pain coupled with >70% ST resolution (in the index lead showing the greatest degree of elevation on presentation) is highly sugges- tive of restoration of normal myocardial blood flow. Complete (or near complete) ST-segment resolution at 60 or 90 minutes after fibrinolytic therapy is a useful marker of a patent infarct Conversely, partial or absent improvement in the extent of ST elevation is not as accurate in predicting a closed Lack of improvement in ST resolution is associ- ated with worse prognosis.349,352,353 The combination of <50% ST resolution and the absence of reperfusion arrhythmias at 2 hours after treatment predicts TIMI flow <3 in the infarct artery with a sensitivity of 81%, specificity 88%, positive predictive value 87%, and negative predictive value 83%.347 Lack of resolution of ST elevation by at least 50% in the worst lead at 60 to 90 min- utes should prompt strong consideration of a decision to proceed with immediate coronary angiography and rescue PCI. 5.3. Transfer to a PCI-Capable Hospital After Fibrinolytic Therapy See Figure 2. 5.3.1. 