What is your intraprocedural approach to reducing time to reperfusion in STEMI cases: opting for culprit lesion PCI first then complete angiography, or complete angiography followed by culprit lesion PCI?

Great inquiry. A lot of it depends on the clinical acuity of the presentation as well as systems-based processes as well. If the patient is more unstable with hypotension/bradycardia or other unstable vital parameters, and the EKG is clearly pointing to a certain territory, then in order to avoid delay to avoid further decompensation, I will go with culprit lesion PCI first if I am sure of the territory (choosing a RCA guide for right or left guide for something pointing anterior territory).

Also, if I am aware of some systems issues that led to delays for patients getting to the cath lab (for example, maybe the ER did not get EKG as early as possible when the patient arrived, so the STEMI page activated later - prolonging Door to balloon ...

Complete angiography first, it's quick and gives you a lot of info. Sometimes you're surprised, ex the territory you thought based on EKG is a CTO and the culprit is actually somewhere else.