Pathways of Care for Patients Who Undergo Primary Percutaneous Coronary Intervention for STEMI: A Review of "Ideal" vs. "Real-world" Clinical Scenarios

Care processes and outcomes for patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remain heterogeneous. A “patient pathway” framework—defined as the sequence of clinically relevant events from symptom onset through diagnosis, reperfusion, and early recovery—can help identify real-world points of failure and opportunities for system-level improvement. In this narrative review, we contrast an “ideal” STEMI pathway with the pathways commonly observed in routine practice for patients treated with primary PCI, and we contextualize deviations from best practice from patient, clinician, health service, and societal perspectives. From the patient's perspective, the priority is rapid symptom recognition and seeking care; however, delays are frequent, particularly in individuals with mild, atypical, or non-classical presentations, prolonging total ischemic time and increasing myocardial injury. Clinicians aim to diagnose STEMI promptly and initiate evidence-based therapy and reperfusion without delay, yet diagnostic uncertainty and competing differentials can contribute to missed or late diagnoses. Health systems seek to provide timely, efficient, and cost-effective emergency revascularization, but performance is influenced by pre-hospital logistics, triage, catheterization laboratory availability, and inter-hospital transfer processes. At the societal level, STEMI imposes substantial mortality, morbidity, and economic burden through premature death and disability. We synthesize evidence on delays to revascularization, misdiagnosis, populations at risk for atypical presentation, and pragmatic interventions to improve care. We conclude that pathway-based analyses offer a structured approach to defining desirable STEMI care trajectories and to reducing missed opportunities for better outcomes.