Since its introduction almost 40 years ago, the procedural safety of percutaneous coronary intervention (PCI) has improved enormously. In particular, the need for emergency coronary artery bypass grafting (CABG) has strikingly diminished, although it has not been eliminated. In consequence of this remarkable achievement, the requirement that PCI should be conducted only in centers with cardiac surgery available on-site has been gradually relaxed. In parallel with this change, primary PCI (PPCI) as immediate treatment for acute ST-elevation myocardial infarction (STEMI) has been shown to be superior therapy when it can be performed rapidly after infarction onset. These 2 forces together have led to growth in the number of centers with catheterization facilities that perform PCI without on-site cardiac surgery. Many of these centers are smaller hospitals in rural or suburban areas, and part of the justification was that they can be more rapidly and easily accessible to patients with STEMI than the more urban and distant hospitals with on-site surgical availability. Studies show that these smaller centers also are performing PCI for indications other than STEMI, that is, for urgent, nonurgent, and elective indications.