In acute ST-Elevation Myocardial Infarction (STEMI) with anticipated delay in catheterization (cath) lab evaluation, when should thrombolysis be considered?

From the Guidelines

Thrombolysis should be considered in acute ST-Elevation Myocardial Infarction (STEMI) with anticipated delay in catheterization lab evaluation when the delay is expected to be more than 120 minutes.

Key Considerations

• The decision to administer thrombolysis is based on the anticipated delay to primary percutaneous coronary intervention (PCI) and the time from symptom onset.
• According to the 2017 AHA/ACC guidelines, fibrinolytic therapy should be administered to patients with STEMI at non-PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays 1.
• The 2015 American Heart Association guidelines also suggest that in STEMI patients presenting within 2 to 3 hours after symptom onset, immediate fibrinolysis rather than primary PCI may be considered when the expected delay to primary PCI is more than 60 minutes 1.
• The 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations provides a guideline for treatment delays versus transport for PCI, recommending fibrinolysis when the anticipated delay is more than 120 minutes 1.
• It is essential to consider the time from symptom onset, anticipated time delay to PCI, and other patient factors such as comorbidities, infarct location, and infarct size when deciding between primary PCI and fibrinolysis 1.

Important Points

• Fibrinolysis is most effective in terms of myocardial salvation and survival in patients with STEMI presenting within 2 to 3 hours after the onset of symptoms.
• Primary PCI is preferred when it can be performed with a time delay of less than 60 minutes in patients presenting less than 2 hours after symptom onset.
• In patients presenting more than 6 hours after symptom onset, primary PCI may represent the best option for reperfusion even if this can only be accomplished with a long delay to primary PCI.

From the Research

Thrombolysis Consideration in Acute STEMI

• Thrombolysis should be considered in acute ST-Elevation Myocardial Infarction (STEMI) when there is an anticipated delay in catheterization (cath) lab evaluation 2.
• The decision to administer thrombolysis is based on the time from onset of signs and symptoms to the anticipated time of cath lab evaluation, with a goal of keeping the time interval as short as possible 3.
• If primary percutaneous coronary intervention (PCI) cannot be performed within 120 minutes after first medical contact (FMC), thrombolysis should be initiated within 30 minutes after FMC 3.

Time Intervals for Thrombolysis Consideration

• The time delay between the onset of symptoms and the first medical contact (FMC) is crucial, with a goal of keeping this interval as short as possible 3.
• The time delay between FMC and the beginning of reperfusion is also critical, with a goal of performing primary PCI within 120 minutes after FMC 3.
• If primary PCI is not possible within 120 minutes, thrombolysis should be considered, with a goal of initiating therapy within 30 minutes after FMC 3.

Factors Influencing Thrombolysis Decision

• The patient's presentation, including the time from onset of symptoms to FMC, is a key factor in determining the need for thrombolysis 2.
• The availability of cath lab resources and the distance to the nearest cath lab are also important considerations 4, 5, 6.
• The patient's clinical condition, including the presence of cardiogenic shock or heart failure signs/symptoms, may also influence the decision to administer thrombolysis 4.