Door-to-needle performance in African ST-elevation myocardial infarction management: A systematic review and
Carlson Sama1, Efeturi Okorigba2, Saim Rana2
1Department of Cardiology, Heart and Vascular Institute, West Virginia University Hospital, Morgantown, WV, USA.
Insights
African STEMI patients face significant delays in fibrinolysis, with door-to-needle times more than double the recommended 30 minutes. This meta-analysis highlights the urgent need for improved workflows to ensure timely reperfusion and better cardiovascular outcomes.
Area of Science:
- Cardiology
- Public Health
- Health Systems Research
Background:
- Timely fibrinolysis is crucial for ST-elevation myocardial infarction (STEMI) reperfusion, especially where primary percutaneous coronary intervention (PCI) is unavailable.
- International guidelines advocate for a door-to-needle time (DTNT) of 30 minutes or less for fibrinolytic therapy.
Purpose of the Study:
- To conduct the first continent-wide meta-analysis assessing real-world DTNTs in African hospitals.
- To evaluate adherence to guideline benchmarks for fibrinolysis in STEMI patients across Africa.
Main Methods:
- Systematic literature search of PubMed/MEDLINE, Scopus, and Web of Science for studies on DTNT in African STEMI patients treated with thrombolysis.
- Random-effects meta-analysis used to estimate pooled mean DTNT, with heterogeneity assessed using Cochran's Q and I² statistics.
Main Results:
- The meta-analysis included 12 studies with 2193 STEMI patients; 57.5% received thrombolytic therapy.
- The pooled mean DTNT was 74.8 minutes, significantly exceeding the 30-minute guideline benchmark.
- Only 36.3% of treated patients achieved a DTNT of ≤30 minutes; no study reported an overall mean DTNT within the target time.
Conclusions:
- African STEMI patients experience substantial delays in fibrinolysis, with DTNTs more than twice the recommended time.
- Fewer than 40% of patients receive timely fibrinolysis, necessitating urgent implementation of standardized protocols and quality improvement initiatives.
- Accelerating fibrinolysis is critical for myocardial salvage and reducing adverse cardiovascular outcomes in settings with limited PCI access.
Background:
Timely fibrinolysis remains the cornerstone of reperfusion for ST-elevation myocardial infarction (STEMI) in settings without reliable access to primary percutaneous coronary intervention (PCI). International guidelines recommend a door-to-needle time (DTNT) of 30 min or less.
Aim:
We conducted the first continent-wide meta-analysis to quantify real-world DTNTs and adherence to guideline benchmarks in African hospitals.
Methods:
We systematically searched PubMed/MEDLINE, Scopus, and Web of Science through July 2, 2025, for studies reporting DTNT for adult STEMI patients treated with thrombolysis in Africa. Pooled mean DTNT was estimated via random-effects meta-analysis with restricted maximum likelihood and Knapp-Hartung adjustment. Heterogeneity was assessed by Cochran's Q and I 2, and sensitivity analyses evaluated robustness.
Results:
Across 12 eligible studies encompassing a total of 2193 STEMI patients, about 1261 individuals (57.5%) received thrombolytic therapy. Among the 11 studies reporting mean reperfusion times (1011 patients), the overall pooled mean DTNT was 74.8 min (95% confidence interval: 44.4-105.2; I 2 = 99.4%), substantially exceeding the recommended benchmark. Notably, only 36.3% of thrombolyzed patients achieved a DTNT of ≤30 min. Furthermore, none of the included study cohorts reported an overall mean DTNT within 30 min.
Conclusion:
African STEMI patients experience door-to-needle delays more than twice the guideline target, with fewer than 4 in 10 receiving timely fibrinolysis. In such settings lacking widespread PCI, implementation of standardized reperfusion protocols, optimized in-hospital workflows, and targeted quality-improvement initiatives is urgently needed to accelerate fibrinolysis, maximize myocardial salvage, and reduce adverse cardiovascular outcomes.
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