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Controversy surrounds the optimal management of high-risk ST-segment-elevation MI in patients who are admitted to hospitals unequipped for percutaneous coronary intervention and who cannot be transferred quickly for primary PCI. In the industry-supported TRANSFER-AMI trial, 1059 such patients received full-dose fibrinolytic therapy (tenecteplase) plus unfractionated heparin or enoxaparin, then were randomized to transfer to a suitable hospital for PCI <6 hours after fibrinolytic therapy or to standard treatment (including transfer for rescue PCI or elective angiography >24 hours later). All patients (median age, mid-50s; 80% men) had a systolic blood pressure of <100 mm Hg, a heart rate of >100 beats per minute, Killip class II or III, ST d…