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Reconsidering fibrinolysis in selected patients with non-ST-elevation acute coronary syndrome: A

Cesar Rodrigo Zoni1, Debabrata Mukherjee2, Martha Gulati3

  • 1Teaching and Research Department at Instituto de Cardiologia de Corrientes "Juana F. Cabral", Corrientes, Argentina.

American Heart Journal
|July 31, 2026
PubMed

Insights

Fibrinolytic therapy, previously contraindicated for non-ST-elevation acute coronary syndrome (NSTE-ACS), may be reconsidered for select patients. Advanced diagnostics can identify NSTE-ACS patients with acute coronary occlusion who might benefit from fibrinolysis when timely reperfusion is unavailable.

Area of Science:

  • Cardiology
  • Emergency Medicine
  • Artificial Intelligence in Healthcare

Background:

  • Major guidelines have historically contraindicated fibrinolytic agents for non-ST-elevation acute coronary syndrome (NSTE-ACS) due to unproven benefits and bleeding risks.
  • Recent advancements in artificial intelligence (AI)-powered electrocardiography (ECG) enable the identification of NSTE-ACS subgroups with acute coronary artery occlusion.
  • These subgroups may warrant immediate reperfusion strategies, challenging existing contraindications.

Purpose of the Study:

  • To evaluate the potential risks and benefits of fibrinolytic therapy in specific NSTE-ACS patient populations.
  • To propose research avenues and clinical criteria for the selective, evidence-based exploration of fibrinolysis in NSTE-ACS.
  • To outline a framework for investigating fibrinolysis in NSTE-ACS patients with probable acute coronary occlusion identified by advanced diagnostics, particularly when timely percutaneous coronary intervention (PCI) is inaccessible.

Main Methods:

  • Review of existing clinical guidelines and recent diagnostic advancements, including AI in ECG interpretation.
  • Analysis of the risk-benefit profile of fibrinolytic therapy in the context of NSTE-ACS.
  • Development of a hypothesis-generating research framework for selective fibrinolysis application.

Main Results:

  • AI-driven ECG analysis can identify NSTE-ACS patients with acute coronary occlusion who were previously undiagnosed.
  • This identification creates a potential subgroup where fibrinolysis might be considered, contrary to current guidelines.
  • The study outlines criteria for research into fibrinolysis for selected NSTE-ACS patients lacking timely PCI.

Conclusions:

  • This article does not advocate for immediate changes in clinical practice regarding fibrinolysis in NSTE-ACS.
  • It proposes a research-based approach to explore the potential utility of fibrinolytic therapy in highly selected NSTE-ACS patients with acute coronary occlusion, especially when timely PCI is unavailable.
  • Further research is needed to establish safety and efficacy in this specific patient cohort.

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