Fibrinolysis Is Still in Use—So Why Isn’t It Better Studied?
In April, the Cardiac Society of Australia and New Zealand released a long-awaited update to their 2016 guidelines. The new Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 offers a clearer, more practical approach—finally, a version designed for real-world use.
Instead of dense text that buries key recommendations, this update includes well-designed tables and a user-friendly layout. Importantly, it keeps rural clinicians front of mind. For example, the approach to ST-elevation myocardial infarction (STEMI) includes a dedicated section for fibrinolysis—essential in settings without immediate access to percutaneous coronary intervention (PCI).
One important change for rural teams: the maximum time allowed to get a patient to primary PCI has been extended from 90 to 120 minutes from first medical contact. For the cardiac nerds among us (and let’s face it, many rural researchers qualify), check out the capsule summary below for the rationale behind this shift.
The evidence base around fibrinolysis remains thin. While there was renewed interest during the COVID-19 pandemic—when interhospital transfers were limited and clinicians explored non-transport treatment options—few new studies have emerged overall since 2010. In low-income countries and rural regions, fibrinolysis remains common, but much of the guidance still relies on older studies that used different medications than we use today.
That’s why one of RRECN’s current projects is a scoping review of modern pharmaco-invasive STEMI management. We’re mapping the existing evidence and identifying critical gaps to guide future research. It’s a highly relevant and underexplored area—especially given the long transport times, variable PCI access, and clinical complexity faced by rural teams. It’s also generating strong interest among RRECN members.
Watch this space.
Capsule Summary:
Why the PCI Time Window Was Extended
Previously, if it was going to take more than 90 minutes from first medical contact (FMC) to perform PCI, fibrinolysis was recommended instead. The new guideline extends that time window to 120 minutes, based on a recommendation from the 2017 European Society of Cardiology (ESC) guidelines.
However, it’s a bit complex, because the ESC guidelines also redefined FMC—not as the moment a clinician first sees the patient, but as the time when the STEMI diagnosis is actually made. Since the ESC guidelines aim for diagnosis within 10 minutes of contact, they effectively provide a 10-minute buffer before starting the PCI countdown.
The logic behind extending the PCI window to 120 minutes is that it reflects the delays seen in early studies comparing PCI and fibrinolysis. But those older studies were done before the development of modern “pharmaco-invasive” approaches and used different drugs and techniques than we use today—so it’s not a perfect comparison.
First published in the RRECN Newsletter (August 2025).
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