PCI 

RANSFER FOR PRIMARY PERCUTANEOUS CORONARY ANGIOPLASTY IN ACUTE ST SEGMENT ELEVATION MYOCARDIAL INFARCTION GUIDELINE

Primary percutaneous coronary intervention (PPCI) is the default reperfusion treatment for patients who present or develop ST segment elevation myocardial infarction (STEMI).

 Inclusion criteria. 

Symptoms compatible with acute ST segment myocardial infarction (STEMI) within the last 12 hours AND with the following electrocardiogram (ECG) criteria: 

  ST segment elevation >1mm or more in contiguous limb leads or >2mm in contiguous chest leads 

  Left Bundle Branch Block (LBBB) believed to be new in the context of acute cardiac sounding chest pain 

 Patients resuscitated from cardiac arrest with ECG criteria as above. 

GUIDELINE

Percutaneous coronary intervention (PCI), is a procedure carried out under

local anaesthetic in which a stenosis (narrowing) of the coronary artery is 

dilated with a balloon catheter and is then treated with a stent (tubular metal 

alloy device) which is implanted into the artery. The stent provides a 

permanent internal scaffold to maintain patency of the artery. 

In patients with a specific form of heart attack known as ST segment elevation 

myocardial infarction (STEMI); the artery supplying the relevant area of heart 

muscle is usually completely blocked by a combination of atheroma and blood 

clot. Primary angioplasty (PPCI) is the use of the PCI technique to relieve the 

blockage as the main or first treatment for appropriate patients suffering a 

heart attack.

Primary PCI is the default reperfusion strategy in appropriate patients with 

STEMI, provided it can be performed within 120minutes of diagnosis. (Keeley

et al 2003 and ESC Task Force 2012)

Where primary PCI cannot be performed within 120 minutes of diagnosis or 

when the patient’s clinical condition prevents transfer fibrinolysis should be 

considered. (Andersen 2003 & Widimsky 2000). See Clinical Guideline -

Thrombolysis of Adult Patients with Acute ST Elevation Myocardial Infarction. 

2.1 Diagnosis

Working diagnosis of myocardial infarction must first be made. This is usually 

based on a history of chest pain, often described as a heaviness or pressure 

with radiation to the back, arms, neck or jaw lasting for 20 minutes or more. 

The discomfort may be associated with shortness of breath, nausea or 

vomiting. However it is important to remember that everyone is an individual 

and presents differently. Data suggests that 30% of patients with STEMI 

present with atypical symptoms. (Brieger 2004)

A 12-lead ECG should be obtained and interpreted as soon as possible after 

cardiac pain is reported (Diercks 2006). Within the Emergency Department, 

Acute Admission Units (EAU, AEC) and Coronary Care this should be within 

not more than 8 minutes. Evidence of ST elevation with current cardiac chest 

pain is sufficient to consider the diagnosis of STEMI. 

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 4 of 13

2.2 ECG Inclusion Criteria For Primary PCI

Symptoms compatible with acute myocardial infarction (MI) within the last 12 

hours combined with any of the following electrocardiogram (ECG) criteria: 

 ST segment elevation >1mm or in at least 2 contiguous limb leads.

 ST segment elevation >2mm in at least 2 contiguous chest leads.

 Left Bundle Branch Block (LBBB) believed to be new in the context of 

acute cardiac sounding chest pain 

 Patients resuscitated from cardiac arrest with ECG criteria as above.

Patients with LBBB believed to be pre-existing and appropriate history for MI 

should be discussed with the PPCI service. 

The inclusion criteria are evidence based to maximise patient benefit; in 

exceptional circumstances, if the senior on-site clinician considers a patient 

does not meet the standard inclusion criteria, but might still benefit from PPCI, 

they should discuss the case with the on-call interventionist at the New Cross 

Hospital Heart Attack Centre. 

2.3 Individual Assessment 

STEMI patients presenting to or who develop STEMI whilst under the care of 

The Dudley Group of Hospitals will have access to the 24/7 PPCI based at the 

Heart Attack Centre. In addition, patients who have not fully met the 

ambulance inclusion criteria and have subsequently been brought to this 

hospital may then be considered as suitable candidates following further 

clinical assessment and/or discussion of their case with a specialist clinician at 

the local Heart Attack Centre. On identification of such a patient, transfer must 

be arranged urgently to minimise any delays.

The first step is to explain the treatment options to the patient and to gain 

consent for transfer as described in section 2.4. If consent cannot be achieved 

(e.g. due to lack of capacity) then it is the responsibility of the senior clinician 

present to decide what actions are in the patient’s best interests (in those 

circumstances relatives and/or carers should always be consulted if 

available).

For patients where there is some doubt as to the appropriateness of referral a 

discussion between the referring hospital (The Dudley Group NHSFT) and the 

Heart Attack Centre should be carried out with a minimum of delay. 

Should discussion be required regarding an individual case with the on call 

interventional cardiologist, then the patient’s ECG can be faxed to the Heart 

Attack Centre on 01902 695 735 and contact made with the on call 

interventional team. 

Once the patient has been assessed as being a suitable candidate to receive 

PPCI they will then be immediately transferred to the Heart Attack Centre via 

emergency ambulance.

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 5 of 13

2.4 Patient Preference

When a patient is considered suitable for PPCI the final determination in the 

selection of this treatment strategy must always be that of patient preference. 

In obtaining the agreement to transfer, it is important that the patient 

understands the reasons for transfer to the Heart Attack Centre. 

The patient explanation script for PCI transfer Appendix 1 should be used to 

aid the patient in understanding this. In the rare circumstance that a patient 

refuses transfer they must be made aware of the increased risk of mortality 

and morbidity of not receiving PPCI.

The clinician is only obtaining patient agreement to transfer for further 

assessment at the Heart Attack Centre. 

2.5 Emergency Ambulance Transfer - 01384 215 520

The local hospital team must arrange an emergency ambulance transfer to 

the Heart Attack Centre by telephoning West Midlands Ambulance Control 

directly. 01384 215 520.

On being connected to the ambulance despatcher inform them that you 

require an “Immediate Critical Transfer for Primary PCI” The call will be 

treated as Category A and given an immediate response. 

The dispatcher will require a series of pre determined questions to be 

answered. State the patient’s name, age, location (ward or department) and 

medical condition as being Heart Attack for PCI. 

Ensure that a Paramedic Crew is assigned and that Oxygen and Defibrillator 

are provided for transfer from the ward / department.

If a relative of the patient is in attendance and they wish to travel then the 

dispatcher should be informed. Only 1 relative is permitted to travel on the 

vehicle and this is at the discretion of the crew who attend. 

2.6 Alert Heart Attack Centre. – 01902 694 339 

The local hospital clinician must then inform the Heart Attack Centre of the 

patient by telephoning the dedicated number. 01902 694 339.

The Heart Attack Centre should be provided with as much information as 

possible regarding the patient. As a minimum this should include:-

 Patient demographics

 Symptom onset and character of pain. 

 Territory of infarct /ECG evidence of STEMI

 Relevant past medical history and cardiac risk factors. 

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 6 of 13

This should be done after requesting an emergency ambulance, to ensure the 

transfer is as quick as possible. This will ensure the Heart Attack Centre has 

sufficient time to activate internal protocols that will ensure the PPCI team and 

the catheter labs are ready to receive the patient.

The local hospital clinician must then ensure that a ‘Hospital PPCI Transfer 

Checklist’ Appendix 2 is completed and placed with the patient’s notes, on 

transferring the patient to the Heart Attack Centre.

2.7 Relief Of Pain, Breathlessness And Anxiety (Mona)

Relief of pain is of paramount importance. Pain is associated with sympathetic 

activation that causes vasoconstriction and increases the workload of the 

heart. 

Diamorphine 2.5mg-5mg is the drug of choice. This may be repeated as 

required and titrated to individual’s level of pain and respiratory rate. 

Anti-emetics (Metoclopramide 10mg IV) should be administered concurrently 

with opioids to minimize nausea. (Rushton 2014)

Non invasive monitoring of blood oxygen saturation greatly helps when 

deciding on the need and percentage of oxygen to be administered. When 

non invasive monitoring is not immediately available oxygen should be 

administered to those who are breathless, hypoxic or who have heart failure.

(ESC 2012) 

Oxygen by mask or nasal prongs should only be used when necessary to 

maintain Sp02 of between 94-98% in the normal population and between 88-

92% in patients with a history of respiratory disease.

2.8 Peri-Procedural Pharmacotherapy

Patients undergoing primary PCI should receive a combination of Dual 

Antiplatelet Therapy (DAPT) with aspirin and an adenosine diphosphate 

(ADP) receptor blocker, as early as possible before angiography.

Aspirin 300 mg should preferably be given orally and chewed, to ensure 

complete inhibition of TXA2-dependent platelet aggregation. (ISIS2 1988)

The ADP-receptor blocker of choice is Ticagrelor 180mg oral loading. 

(Wallentin et al 2009) Ticagrelor is contraindicated in patients with a previous 

haemorrhagic stroke.

If Ticagrelor is contraindicated due to above reason then Clopidogrel 600mg 

oral loading should be given instead. (Mehta et al 2010)

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 7 of 13

2.9 The Ventilated Patient

In patients with resuscitated cardiac arrest, whose ECG shows ST-segment 

elevation, immediate angiography with a view to primary PCI is the strategy of 

choice, provided that the guidelines mandated times can be met. (Garot 2007 

& Kern 2010). 

Unfortunately, the prognosis of these patients remains poor and an 

individualised assessment must be made before deciding on whether to 

transfer for PPCI. All ventilated patients must be discussed with the Heart 

Attack Centre prior to transfer. The following information must be available 

prior to discussion:

1) Arterial blood gas findings – specifically pH, lactate, base excess

2) ‘Down time’ and whether bystander CPR was initiated before first medical 

contact

3) Rhythm at the time of assessment by paramedics and any interventions

4) Total resuscitation time

5) Glasgow coma scale

6) Current observations – BP, heart rate, temperature, respiratory rate

7) Relevant co-morbidities and patient’s normal activity levels

The following have been associated with poor outcomes:

1) Unwitnessed arrest

2) Initial rhythm: Non-VF

3) No bystander CPR

4) >30 min to ROSC

5) Ongoing CPR

6) pH <7.2

7) Lactate >7

8) Age >85

9) End stage renal disease

10) Non - cardiac causes (e.g;,traumatic arrest)

In patients who have maintained a return of spontaneous circulation (ROSC) 

but still require ventilator support the Dudley Group ICU medical staff must be 

involved at the earliest opportunity to facilitate the safe and rapid transfer of 

the patient for Primary PCI. Bleep 6012 or phone ICU ext. 2070 / 2649

On referring the patient The Heart Attack Centre should be informed that the 

patient is intubated and request that a Cardiac Intensivist is available in the 

Cardiac Catheter Laboratory New Cross Hospital when the patient arrives. 

It is the responsibility of the Heart Attack Centres on call cardiology registrar 

to ensure that a cardiac intensivist is available to receive handover of care 

from The Dudley Group ICU medical staff. The Dudley Group ICU staff must 

be given the name and contact details of the cardiac intensivist meeting them. 

After being met at the centre by the receiving team and the patient having 

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 8 of 13

been handed over, the Dudley Group NHS Foundation Trust ICU team will 

return.

New Cross Cardio-Thoracic ICU direct line 01902 694260 / 694261

It is the responsibility of the Heart Attack Centres Cardiac Nurse Co-ordinator

to facilitate a Cardiac ICU bed or if not available following PCI a General ICU

bed on the Wolverhampton site.

In preparing the patient for transfer the key priorities are to ensure a safe 

secure airway. This is a time critical transfer and only interventions that are 

required to be undertaken to ensure the patient is safe are required. Please 

see Russell’s Hall Critical Care Unit Transport Checklist

2.10 Transfer Of Care.

The patient remains the responsibility of the team caring for the patient until 

they have been handed over to WMAS and have left the department. 

Any changes in the patients condition prior to transfer that were not previously 

communicated to the Heart Attack Centre should be added to the transfer 

document and verbally communicated to the Heart Attack Centre via the 

Primary PCI Referral Line.

WMAS are unable to manage any drug infusions commenced prior to transfer. 

In this instance an appropriately trained escort will be required to travel with 

the patient. Cardiac Assessment Nurses should not be relied upon to transfer 

patients. It is the responsibility of the nurse in charge of the department to 

ensure appropriately qualified staff, escort the patient whilst maintaining local 

staffing levels. 

3. DEFINITIONS/ABBREVIATIONS

STEMI ST segment elevation myocardial infarction

ECG 12 Lead Electrocardiogram

PPCI Primary Percutaneous Coronary Intervention

LBBB Left Bundle Branch Block

PCI Percutaneous Coronary Intervention

ESC European Society of Cardiology

MI Myocardial Infarction

HAC Heart Attack Centre Wolverhampton

WMAS West Midlands Ambulance Service

Category A

Level of priority given to 999 ambulance call which 

dictates a response within 8minutes.

mg Milligrams

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 9 of 13

IV Intravenous

Sp02 Saturation of peripheral oxygen

DAPT

Dual anti-platelet therapy. – The use of two 

antiplatelet drugs to effect platelet aggregation

ADP receptor inhibitor

Adenosine diphosphate receptor inhibitor. - class 

of antiplatelet agents

ROSC Return of Spontaneous Circulation

ICU Intensive Care Unit 

ED Emergency Department – Russells Hall 

EAU Emergency Assessment Unit – Russells Hall

AEC Ambulatory Emergency Care – Russells Hall

CAT Cardiac Assessment Team. – Cardiac Specialist 

Nurses – Russells Hall

4. DUTIES (RESPONSIBILITIES)

4.1 The Acute Coronary Syndrome Group - will be responsible for reviewing and 

updating this document in light of new evidence and changes in practice. The 

clinical representatives of this group will facilitate the communication of this 

document amongst their peers.

The group will review incidents that fall within the remit of this procedural 

document and where appropriate advise on local changes to practice.

4.2 The Primary PCI Lead Medical & Nursing New Cross Hospital – will be 

responsible for communicating changes in practice and process to the 

cardiology leads at the Dudley Group. They will also share incidents to inform 

and develop clinical practice.

4.3 The Medical Heads of Service (ED, EAU, AEC and Cardiology) - have 

overall responsibility for clinical activity within their relevant Department and 

ensuring that systems are in place to monitor and audit clinical practice where 

necessary.

The Medical Heads of Service also in collaboration with the Cardiac 

Assessment Nurses are responsible for ensuring an appropriate education 

programme is in place to ensure training of relevant staff regarding this 

guideline

4.4 The Lead Nurses of (ED, EAU, AEC and Cardiology) – have overall 

responsibility for nursing activity within their relevant Department and ensuring 

that systems are in place to monitor and audit clinical practice where 

necessary.

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 10 of 13

The Lead Nurses in collaboration with the Cardiac Assessment Nurses are also 

responsible for ensuring an appropriate education programme is in place to 

ensure training of relevant staff regarding this guideline. 

4.5 The Cardiac Specialist Nurses (Cardiac Assessment Team) – will liaise with 

all relevant parties to ensure the safe and effective implementation of the 

guideline on a daily basis.

They will work with relevant leads and heads of service to develop, implement 

and develop appropriate training.

5. TRAINING/SUPPORT

All clinical staff working within the departments will have access to it on the 

cardiology section of the Hub. Links should also be in place on the ED and 

Acute medicine section of the Hub. 

The ED/EAU/Cardiology education programmes (medical and nursing) will take 

into account the specific educational requirements of clinical staff regarding the 

management of STEMI and the Primary PCI referral process.

6. REFERENCES

Andersen HR et al (2003) Comparison of coronary angioplasty with fibrinolytic 

therapy in acute myocardial infarction. N Engl J Med 2003;349:pp733–742.

Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, Montalescot 

G.

Acute coronary syndromes without chest pain, an underdiagnosed and 

undertreated

high-risk group: insights from the Global Registry of Acute Coronary

Events. Chest 2004;126:461–469.

Diercks DB, et al (2006) Frequency and consequences of recording an 

electrocardiogram 10 minutes after arrival in an emergency room in non-STsegment

elevation acute coronary syndromes (from the CRUSADE Initiative). Am J 

Cardiol 2006;97:437–442

European Society of Cardiology [ESC] 2012 Management of acute myocardial 

infarction in patients presenting with persistent ST-segment elevation: The Task 

Force on the management of ST-segment elevation European Heart Journal 

(2012) 29, pp2909–2945

Garot P, et al (2007). Six-month outcome of emergency percutaneous coronary 

intervention in resuscitated patients after cardiac arrest complicating STelevation myocardial infarction. Circulation 2007; 115: pp1354–1362.

Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous 

thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 

randomised trials. Lancet. 2003:361:13-20.

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 11 of 13

Kern KB and Rahman O (2010) Emergent percutaneous coronary intervention 

for resuscitated victims of out-of-hospital cardiac arrest. Catheter 

Cardiovascular International 2010;75: pp616–624.

Mehta SR, et al 2010. Double-dose versus standard-dose clopidogrel and highdose versus low-dose aspirin in individuals undergoing percutaneous coronary

intervention for acute coronary syndromes (CURRENT-OASIS 7): a 

randomised factorial trial. Lancet 2010;376: pp1233–1243.

Rushton, Melanie (2014) Administration of Intermittent IV Opioids for Acute 

Pain Management in Adults Guideline. 

Wallentin L, etal (2009). Ticagrelor versus clopidogrel in patients with acute 

coronary syndromes. N Engl J Med 2009;361:pp 1045–1057.

Widimsky P, etal (2000). Multicentre randomized trial comparing transport to 

primary angioplasty vs immediate thrombolysis vs combined strategy for 

patients with acute myocardial infarction presenting to a community hospital 

without a catheterization laboratory. Eur Heart J. 2000;21:823-31. 

Transfer for Primary PCI for patients with acute STEMI January 2017 Version 0.1 Page 12 of 13

Appendix 1

‘Script’ to be read to patients being transferred from Dudley Group 

NHS Foundation Trust to Heart Attack Centre for assessment for 

PPCI

The following does not have to be read verbatim but these are the key facts which 

should be relayed to the patient prior to transfer to the Heart Attack Centre 

Wolverhampton for assessment for primary PCI.

Diagnosis of Heart Attack. 

 We believe that you are having a heart attack

 This is caused by a narrowing and a blood clot forming in one of the heart’s 

blood vessels 

 The area of heart muscle that this blood vessel supplies is starved of oxygen and 

is likely to be the cause of your symptoms

 The aim of treatment is to re-open this blocked vessel in order to restore blood 

flow and so minimise the damage done to the heart

Treatment - Primary angioplasty

 This is a procedure not a surgical operation. 

 You will not require an anaesthetic but may receive medications so you feel 

more relaxed.

 It involves passing a fine tube, via the wrist or groin, into the blood vessels of the 

heart and physically unblocking the clot / opening the narrowing.

Location – Heart Attack Centre Wolverhampton.

 To get the primary angioplasty treatment we will need to transfer you 

immediately by emergency ambulance to the Heart Attack Centre.

 The Local Heart Attack Centre for this area is in Wolverhampton on the site of 

New Cross Hospital. 

 This allows for specialist operators who specialise in this treatment to 

concentrate their skills and treat a greater number of people. 

Post Procedure

 Patients who undergo PPCI tend to stay in hospital 2-3days

 Unless your recovery is delayed, you will remain at the Heart Attack Centre for 

your hospital care. 

 After discharge from the Heart Attack Centre your details will by passed back to 

Cardiology at Dudley Group NHS and your on going care and follow up will be 

provided locally.