* Experienced coronary care unit nursing staff comfortable with invasive hemodynamic monitoring, operation of temporary pacemaker, and management of IABP. Personnel capable of endotracheal intubation and ventilator management both on-site and during transfer if necessary. Full support from hospital administration in fulfilling the necessary institutional requirements, including appropriate support services (eg, respiratory care, blood bank). Written agreements for emergency transfer of patients to a facility with cardiac surgery. Transport protocols should be developed and tested a minimum of 2 times per year. Well-equipped and maintained cardiac catheterization laboratory with high-resolution digital imaging capability and IABP equipment compatible with transport vehicles. The capability for real-time transfer of images and hemodynamic data (via T-1 transmission line) as well as audio and video images to review terminals for consultation at the facility providing surgical backup support is ideal. Appropriate inventory of interventional equipment, including guide catheters, balloons, and stents in multiple sizes; thrombectomy and distal protection devices; covered stents; temporary pacemakers; and pericardiocentesis trays. Pressure wire device and IVUS equipment are optimal but not mandatory. Rotational or other atherectomy devices should be used cautiously in these facilities because of the greater risk of perforation. Meticulous clinical and angiographic selection criteria for PCI (Tables 6 and 7). Performance of primary PCI as the treatment of first choice for STEMI to ensure streamlined care paths and increased case volumes. Door-to-balloon times should be tracked, and 90 min outlier cases should be carefully reviewed for process improvement opportunities. On-site rigorous data collection, outcomes analysis, benchmarking, quality improvement, and formalized periodic case review. Participation in a national data registry where available, such as the ACC NCDR in the United States. *Required for US facilities but may not be possible for all facilities worldwide. 