Cardiovascular

Timely Reperfusion in STEMI: A Closed-Loop Audit of Guideline Compliance and Practice Improvements.

Murray C, Carey J, Karlsson R, Pearson I • Irish medical journal • 2026

PubMed 42936602
TL;DR

A regional protocol promoting pre-transfer thrombolysis substantially increased thrombolysis utilisation and improved overall timely reperfusion among STEMI patients transferred from outside Dublin, though geographical disparities persist at the periphery of the region.

Key Findings

Results

Median ECG-to-reperfusion time among STEMI patients transferred from outside Dublin decreased after the protocol change.

  • Median time fell from 124 minutes (IQR 96-166) to 113 minutes (IQR 78-151) (p<0.0001).
  • The primary outcome was time from first ECG to reperfusion.
  • Observational study at St. James's Hospital comparing 2021-2023 with a prior cohort (2017-2020).
Results

The proportion of transferred patients achieving reperfusion within the 120-minute target increased.

  • Rose from 235/507 (46.4%) to 308/530 (58.1%) among patients transferred from outside Dublin.
  • The 120-minute target had often been exceeded in the initial audit, prompting the protocol update.
Results

Overall thrombolysis use increased markedly after Dublin Mid Leinster protocols recommended pre-transfer thrombolysis.

  • Thrombolysis use rose from 27/1161 (2.3%) to 131/1301 (10.1%).
  • The updated protocol recommended thrombolysis before transfer for patients unlikely to reach primary PCI in time.
Results

Thrombolysis was successful in about two-thirds of thrombolysed patients.

  • 85/131 (64.9%) achieved successful reperfusion, defined as TIMI 2/3 flow on angiography.
  • Success was a pre-specified secondary outcome.
Results

Severe bleeding was uncommon among thrombolysed patients.

  • Severe bleeding occurred in 2/131 (1.5%) thrombolysed patients.
  • Safety was a pre-specified secondary outcome.
Results

Geographical mapping showed markedly lower rates of timely reperfusion at the periphery of the Dublin Mid Leinster region.

  • Disparities persisted despite overall improvement.
  • The authors suggest these support further optimisation of regional pathways and consideration of prehospital thrombolysis strategies.
Methods

The study was a closed-loop audit of a regional STEMI pathway including 1,301 patients in the recent cohort.

  • An initial audit found patients transferred from emergency departments outside Dublin often exceeded the 120-minute reperfusion target.
  • The re-audit evaluated reperfusion times and outcomes after protocol changes.
  • Design was observational with a historical comparison cohort (2017-2020), so causal attribution is limited.

What This Means

Quickly reopening a blocked heart artery is crucial for people having a major heart attack (STEMI). An earlier audit in Ireland found that patients sent to St. James's Hospital in Dublin from emergency departments outside the city often missed the 120-minute target for treatment. In response, regional guidelines were changed to recommend giving clot-busting drugs (thrombolysis) before transfer when timely angioplasty was unlikely. Comparing 2021-2023 with 2017-2020, the study found that thrombolysis use rose from about 2% to 10% of patients. Among those transferred from outside Dublin, the median time from first ECG to reopening the artery fell from 124 to 113 minutes, and the share treated within 120 minutes rose from 46% to 58%. About 65% of thrombolysed patients had successful reperfusion, and severe bleeding was seen in 1.5%. This research suggests that regional protocols encouraging thrombolysis can improve treatment times for patients far from a major heart centre. However, patients living at the edges of the region still had much lower rates of timely treatment, so further changes, such as clot-busting treatment given by ambulance crews, may be worth considering. Because this was an observational comparison with an earlier group, it cannot prove the protocol was the sole cause of the improvements.

Have a question about this study?

Presence or severity of Hashimoto's thyroiditis does not influence basal calcitonin levels: observations from CROHT biobank.
Journal of endocrinological investigation • 2022

HT patients of all disease stages preserve Ct production as healthy individuals and there is no need for Ct measurements...
Approach to the Patient: Safety of Growth Hormone Replacement in Children and Adolescents.
The Journal of clinical endocrinology and metabolism • 2022

rhGH therapy has been used for more than 3 decades and data are largely reassuring, yet we still have much to learn abou...
Extended Absorption of Liothyronine from Poly-Zinc-Liothyronine: Results from a Phase 1, Double-Blind, Randomized, and Controlled Study in Humans.
Thyroid : official journal of the American Thyroid Association • 2022

PZL possesses the necessary properties to achieve a much improved T3 pharmacokinetic profile, with ~30% lower Cmax that...
Lipoprotein subtypes after testosterone therapy in transmasculine adolescents.
Journal of clinical lipidology • 2022

Testosterone appears to be a major contributor to differences in lipoprotein profiles, a surrogate for cardiovascular di...
Long-term testosterone undecanoate treatment in the elderly testosterone deficient male: An observational cohort study.
Andrology • 2022

Long-acting testosterone undecanoate treatment in elderly testosterone-deficient patients required more frequent dose ad...
Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism.
Clinical endocrinology • 2022

The Society for Endocrinology commissioned a multidisciplinary guideline to provide all care providers with a comprehens...

Citation

Murray C, Carey J, Karlsson R, Pearson I. (2026). Timely Reperfusion in STEMI: A Closed-Loop Audit of Guideline Compliance and Practice Improvements.. Irish medical journal. https://pubmed.ncbi.nlm.nih.gov/42936602/