ST-elevation myocardial infarction late-presenting patients: time for a new paradigm?

Timely performed percutaneous coronary angioplasty (PCI) remains the most critical factor predicting favorable outcomes in patients with ST-elevation myocardial infarction (STEMI). Guidelines have traditionally identified the first 12 hours from symptom onset as the "golden window" for PCI. However, recommendations for patients presenting beyond this timeframe remain inconsistent. Late presenters are associated with worse outcomes and significantly higher rates of in-hospital mortality. Notably, the recent COVID-19 pandemic has further increased the prevalence of late presentations. Emerging imaging techniques now offer new opportunities to better characterize both patients and the pathological consequences of late-presented STEMI. Despite this progress, evidence supporting the adoption of imaging-guided strategies remains mixed. These advancements hold the potential to pave the way for personalized management approaches for this heterogeneous patient population soon. In this review, we explore the current evidence regarding the treatment of late presenters and discuss how emerging imaging techniques may transform clinical strategies in this challenging subset of STEMI patients.