In these cir- cumstances, the benefits are greatest if PCI is initiated early after fibrinolytic failure. On the other hand, conservative treatment might be reasonable in a patient with improving symptoms and a limited inferior infarction despite persis- tence of ST elevation. 5.3.1.3. Transfer for Routine Early Coronary Angiography After Fibrinolytic Therapy With the introduction of coronary stents and aggressive anti- platelet therapies, there has been renewed interest in imme- diate and early catheterization after fibrinolytic therapy. The advantage of this approach is that it can be initiated at non PCI-capable hospitals and affords the healthcare sys- tem additional time to arrange a nonemergency transfer for angiography and PCI. Routine referral for angiography with the intent to perform PCI is supported indirectly by retrospec- tive analyses from trials of fibrinolytic therapy that suggest that patients treated with PCI during the index hospitalization have a lower risk of recurrent MI and a lower 2-year mortality Table 8. Indications for Transfer for Angiography After Fibrinolytic Therapy COR LOE References Immediate transfer for cardiogenic shock or severe acute HF irrespective of time delay from MI onset I B 354 Urgent transfer for failed reperfusion or reocclusion IIa B 346, As part of an invasive strategy in stable* patients with PCI between 3 and 24 h after successful fibrinolysis IIa B 358 363 *Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia. COR indicates Class of Recommendation; HF, heart failure; LOE, Level of Evidence; MI, myocardial infarction; and PCI, percutaneous coronary intervention. 