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Publications

Journal Article Ahead of print

PubMed: 41821214 DOI: 10.1093/ehjqcco/qcag041

Missed Opportunity for Fibrinolysis in ST-Segment-Elevation Myocardial Infarction: The Nationwide France-PCI Registry.

Eur Heart J Qual Care Clin Outcomes

Authors: Louis-Marie Desroche, Matthieu Daniel, Etienne Puymirat, Youssef Rahal, Marine Quillot, Olivier Nugue, Olivier Tricot, Ouissem Zid, Benoit Herce, Thibault Perret, Laurent Leborgne, Fabrice Prunier, Nicolas Meneveau, Luc Maillard, Franck Barbou, Christophe Robin, Nizar Ben Mansour, Akram Chmait, François Huchet, Yoann Lefrancois, Guillaume Molins, Erwan Bressollette, Guillaume Cayla, Julien Adjedj, Eric Van Belle, Christophe Saint Etienne, René Koning, Hakim Benamer, Philippe Commeau, Stephan Chassaing, Pascal Motreff, Michel Zeitouni, Grégoire Rangé

Affiliations

  • Cardiology Department, University Hospital of La Réunion, Saint-Denis, France.
  • CIC-EC INSERM 1410, University Hospital of La Réunion, Saint-Denis, France.
  • Emergency Department and SMUR, Groupe Hospitalier Est Réunion, University Hospital of La Réunion, BP 186, 97470 Saint-Benoît, La Réunion, France.
  • University of La Réunion, UFR Santé (Campus Terre-Sainte), 77 Avenue Dr Jean Marie Dambreville, 97410 Saint-Pierre, La Réunion, France.
  • University of La Réunion, Pharmaco-Immunology Studies (EPI) Research Unit, CHU La Réunion, Félix-Guyon site, Allée des Topazes, CS 11021, 97400 Saint-Denis, La Réunion, France.
  • Department of Cardiology, AP-HP, Hôpital Européen Georges Pompidou, Paris, France.
  • Paris Cardiovascular Research Center (PARCC), Paris, France.
  • Cardiology Department, Aix-Pertuis Intercommunal Hospital Center (Aix site), Aix-en-Provence, France.
  • Cardiology Department, Avignon Hospital Center (Henri-Duffaut), Avignon, France.
  • Cardiology Department, Boulogne-sur-Mer Hospital Center, Boulogne-sur-Mer, France.
  • Cardiology Department, Dunkerque Hospital Center, Dunkerque, France.
  • Cardiology Department, Le Mans Hospital Center, Le Mans, France.
  • Cardiology Department, Soissons Hospital Center, Soissons, France.
  • Cardiology Department, Saint-Joseph Saint-Luc Hospital Center, Lyon, France.
  • Cardiology Department, Amiens University Hospital, Amiens, France.
  • Cardiology Department, Angers University Hospital, Angers, France.
  • Cardiology Department, Besançon University Hospital (Jean-Minjoz), Besançon, France.
  • Cardiology Department, Clinique Axium, Aix-en-Provence, France.
  • Cardiology Department, Clinique Belledonne, Saint-Martin-d'Hères, France.
  • Cardiology Department, Clinique Convert - Maison du Cœur et des Vaisseaux, Bourg-en-Bresse, France.
  • Cardiology Department, Pôle Santé Sud - Centre Médico-Chirurgical du Mans (CMCM), Le Mans, France.
  • Cardiology Department, Centre MCO Côte d'Opale, Saint-Martin-Boulogne, France.
  • Cardiology Department, Saint-Nazaire Hospital Center, Saint-Nazaire, France.
  • Cardiology Department, Hôpital Nord Franche-Comté, Trévenans, France.
  • Cardiology Department, Hôpital Privé Dijon Bourgogne, Dijon, France.
  • Cardiology Department, Hôpital Privé du Confluent, Nantes, France.
  • Cardiology Department, Nîmes University Hospital, Nîmes, France.
  • Cardiology Department, Institut Arnault Tzanck, Saint-Laurent-du-Var, France.
  • Cardiology Department, Lille University Hospital - Heart & Lung Institute, Lille, France.
  • Cardiology Department, Tours University Hospital (CHRU Trousseau), Tours/Chambray-lès-Tours, France.
  • Cardiology Department, Clinique Saint-Hilaire, Rouen, France.
  • ICPS - Institut Jacques Cartier, Massy, France.
  • Cardiology Department, Les Fleurs Clinic - ELSAN, Ollioules, France.
  • Cardiology Department, Nouvelle Clinique Tours Plus, Tours area, France.
  • Cardiology Department, Clermont-Ferrand University Hospital (Gabriel-Montpied Hospital), Clermont-Ferrand, France.
  • Cardiology Department, Sorbonne Université, Pitié-Salpêtrière Hospital, Action Cœur, UMRS1166 AP-HP, Paris, France.
  • Cardiology Department, Chartres Hospital, Le Coudray, France.

Abstract

BACKGROUND

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 minutes from first medical contact (FMC), guidelines recommend fibrinolysis as early as possible within 12 hours of symptom onset in eligible patients. We quantified missed opportunities for fibrinolysis in a nationwide STEMI network.

METHODS

We analysed consecutive STEMI patients enrolled ≤24 hours from symptom onset in the France-PCI registry (2014-2022). FMC was approximated by the first diagnostic 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.

RESULTS

Among 19,472 patients, 12,633 (64.9%) underwent timely PPCI, 5,895 (30.3%) delayed PPCI, and 944 (4.8%) fibrinolysis. Timely PPCI increased over time, whereas fibrinolysis declined. Among delayed PPCI, 3,279/5,895 (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.

CONCLUSIONS

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.

MeSH

Registries, Myocardial Infarction, Fibrinolysis, Cardiovascular Diseases, Percutaneous Coronary Intervention, St Elevation Myocardial Infarction, Clinical Medicine, Reperfusion