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This editorial refers to ‘Relationship between risk stratification at admission and treatment effects of early invasive management following fibrinolysis: insights from the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)’, by A.T. Yan et al. doi:10.1093/eurheartj/ehr008 Reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI), especially with primary percutaneous coronary intervention (PCI), can reduce mortality by >25%. Earlier reperfusion provides greater benefit, particularly in the early hours of infarction.1Of the large number of remaining questions about how best to apply reperfusion therapy for patients with acute STEMI, few are more important than how to manage the patient who presents to the hospital without PCI capability. When it can be done quickly, transfer for primary PCI is generally the best strategy.2 Yet all too often—70% of the time in the USA from 2005 to 20073—this patient is transferred for primary PCI with long delays (of >120 min first door to device) that rob the patient of the benefits of prompt reperfusion therapy with fibrinolysis. Even with fibrinolysis, whether and when to transfer to a PCI-capable centre, to perform angiography, and to perform PCI has been a topic of intense investigation.There have been at least three published meta-analyses4–6 in the past year of the modest-sized clinical trials that have randomly assigned patients following fibrinolysis to routine early vs. selective (or delayed) coronary angiography and …

Who should have a routine early invasive approach after fibrinolytic therapy?