Missed opportunity for fibrinolysis in ST-segment-elevation myocardial infarction: the nationwide France-PCI registry

Timely reperfusion is a key quality-of-care target in ST-segment elevation myocardial infarction (STEMI). When primary percutaneous coronary intervention (PPCI) cannot be delivered within 120 min from first medical contact (FMC), guidelines recommend fibrinolysis as early as possible within 12 h of symptom onset in eligible patients. We quantified missed opportunities for fibrinolysis in a nationwide STEMI network.

We analysed consecutive STEMI patients enrolled ≤24 h from symptom onset in the France-PCI registry (2014-22). First medical contact was approximated by the first diagnostic electrocardiogram (ECG). Initial reperfusion was classified as timely PPCI (FMC-to-device ≤120 min), delayed PPCI (>120 min), or fibrinolysis. Among delayed PPCI, eligibility for fibrinolysis required no oral anticoagulant, no prior stroke, and no documented contraindication. We evaluated temporal trends, regional variation, and outcomes. Among 19 472 patients, 12 633 (64.9%) underwent timely PPCI, 5895 (30.3%) delayed PPCI, and 944 (4.8%) fibrinolysis. Timely PPCI increased over time, whereas fibrinolysis declined. Among delayed PPCI, 3279/5895 (55.6%) presented within the prespecified early-presenter window (symptom-to-ECG ≤3 h) and met our strict fibrinolysis-eligibility criteria, yet underwent delayed PPCI; this proportion remained stable across years, with marked regional heterogeneity. Fibrinolysis use was favoured by mobile intensive care units, helicopter transport, and longer distance to PPCI centres, whereas older age was associated with delayed PPCI without fibrinolysis.

In this national STEMI network, more than half of delayed PPCI in eligible early presenters represented a persistent missed-fibrinolysis gap. Routine audit of delayed PCI and missed fibrinolysis as system-level quality metrics should guide time-based pre-hospital triage and align reperfusion with guideline-recommended targets.