Regional Systems of STEMI Care and Goals for Reperfusion Therapy Any regional medical system must seek to enable rapid rec- ognition and timely reperfusion of patients with STEMI. System delays to reperfusion are correlated with higher rates of mortality and morbidity.96 100 Although attention to certain performance metrics, such as D2B, door-to-needle, and door-in door-out times, have catalyzed important insti- tutional quality improvement efforts, broader initiatives at a systems level are required to reduce total ischemic time, the principal determinant of outcome.101,102 Questions have been raised about the overreliance on primary PCI for reper- fusion, especially in the United States, and the unintended consequences that have evolved as familiarity with fibrino- lysis has waned.101 The writing committee reiterates the prin- ciple highlighted in the 2004 ACC/AHA STEMI guideline, namely that the appropriate and timely use of some form of reperfusion therapy is likely more important than the choice of therapy. 4 Greatest emphasis is to be placed on the delivery of reperfusion therapy to the individual patient as rapidly as possible. Only a minority of US hospitals are capable of performing and any delay in time to reperfusion (D2B) after hospital arrival is associated with a higher adjusted risk of in-hospital mortality in a continuous, nonlinear fashion.96 Strict time goals for reperfusion may not always be relevant or possible for patients who have an appropriate reason for delay, including initial uncertainty about diagnosis, the need for evaluation and treatment of other life-threatening condi- tions (eg, acute respiratory failure, cardiac arrest), delays involving informed consent, and long transport times due to geographic distance or adverse weather. 