Indications for fibrinolysis in patients with ST-segment elevation myocardial infarction: From guidelines to practice

Background European guidelines on managing ST segment elevation myocardial infarction (STEMI) during the first 12 hours recommend fibrinolysis when the time elapsing between the first medical contact and balloon time (FMCBT) is more than 120 minutes. Aim To assess the real-life clinical efficacy of guidelines on fibrinolysis in managing STEMI and identify obstacles to their everyday implementation. Methods An observational study based on a permanent registry of reperfusion strategies and timing among patients treated in a French general hospital for STEMI with chest pain lasting for less than two hours. Patients were enrolled between January 1 st 2008 and December 31 st 2014. Results The study included 669 patients: 79 (11.8%) benefited from effective fibrinolysis followed by coronary arteriography (PCI) within 24 hours, 445 (66.5%) underwent a primary PCI, 99 (14.8%) received a rescue PCI and 46 (6.9%) did not undergo revascularization. The FMCBT was 120 minutes or longer in 209 patients: fibrinolysis was performed in 68 of these patients (32.5%), and primary PCI in 141 (114 (54.6%) without contraindications to fibrinolysis and 27 (12.9%) with contraindications). The patient's age, female gender, co-morbidities and clinical management were factors that appeared to be linked to poor compliance with the guidelines, but none were significant ( P  > 00.5). Nor were there significant differences regarding bleeding complications between patients receiving fibrinolysis or primary PCI ( P  > 0.05). Conclusion The guidelines on fibrinolysis were not followed in 54.6% of patients when the FMCBT was more than 120 minutes. Some criteria (age, gender, co-morbidities) may have been responsible for this non-compliance, although underestimating the time between first medical contact and arrival in the catheterisation laboratory could not be excluded. Further studies are necessary to improve estimates of this delay.