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Published on: May 28, 2019
Indications for fibrinolysis in patients with ST-segment elevation myocardial infarction: From guidelines to practice
C Boivineau1, L Orion1, J Dimet2
1Cardiologie, CHD de Vendée, 85000 La Roche-sur-Yon, France.
Insights
European guidelines for ST-elevation myocardial infarction (STEMI) recommend fibrinolysis for long first medical contact to balloon times (FMCBT). However, these guidelines were not followed in over half of eligible STEMI patients, indicating implementation challenges.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Guidelines
Background:
- European guidelines recommend fibrinolysis for ST-elevation myocardial infarction (STEMI) when the first medical contact to balloon time (FMCBT) exceeds 120 minutes.
- This study evaluates the real-world effectiveness of these fibrinolysis guidelines in STEMI management.
Purpose of the Study:
- To assess the clinical efficacy of current STEMI management guidelines regarding fibrinolysis.
- To identify barriers to the consistent implementation of these guidelines in clinical practice.
Main Methods:
- An observational study utilizing a permanent registry of reperfusion strategies and timing.
- Data collected from STEMI patients treated in a French general hospital between January 2008 and December 2014.
- Focus on patients with chest pain onset less than two hours prior to enrollment.
Main Results:
- Of 669 STEMI patients, 11.8% received timely fibrinolysis followed by PCI, while 66.5% underwent primary PCI.
- In patients with FMCBT ≥ 120 minutes (n=209), fibrinolysis was administered in only 32.5%, with primary PCI in 54.6%.
- Factors like age, gender, and comorbidities were associated with non-compliance, but not significantly; bleeding complications did not differ between fibrinolysis and primary PCI groups.
Conclusions:
- Guideline adherence for fibrinolysis in STEMI patients with FMCBT > 120 minutes was low (45.4% compliance).
- Potential reasons for non-compliance include patient-specific factors (age, gender, comorbidities) and underestimation of delays in catheterization laboratory access.
- Further research is needed to refine time delay estimations and improve guideline implementation for STEMI management.
Background:
European guidelines on managing ST segment elevation myocardial infarction (STEMI) during the first 12hours recommend fibrinolysis when the time elapsing between the first medical contact and balloon time (FMCBT) is more than 120minutes.
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 1st 2008 and December 31st 2014.
Results:
The study included 669 patients: 79 (11.8%) benefited from effective fibrinolysis followed by coronary arteriography (PCI) within 24hours, 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 120minutes 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 120minutes. 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.
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