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

Abstract

Aim
Timely reperfusion is vital in STEMI care to reduce mortality. An initial audit showed patients transferred from emergency departments outside Dublin often exceeded the 120-minute reperfusion target. In response, Dublin Mid Leinster protocols were updated to recommend pre-transfer thrombolysis. This study evaluates the impact of these changes on reperfusion times and outcomes.

Methods
This observational study included STEMI patients admitted to St. James’s Hospital from 2021–2023, compared to a prior cohort (2017–2020). The primary outcome was time from first ECG to reperfusion. Secondary outcomes included thrombolysis rates, success (TIMI 2/3 flow on angiography) and safety.

Results
Among 1,301 patients, the median ECG-to-reperfusion time among patients transferred from outside Dublin fell from 124 minutes (IQR 96–166) to 113 minutes (IQR 78–151) (p<0.0001), while the proportion achieving reperfusion within 120 minutes increased from 235/507 (46.4%) to 308/530 (58.1%). Overall thrombolysis use increased from 27/1161 (2.3%) to 131/1301 (10.1%). Among thrombolysed patients, 85/131 (64.9%) achieved successful reperfusion and severe bleeding occurred in 2/131 (1.5%). Mapping demonstrated markedly lower rates of timely reperfusion at the periphery of the DML region.

Discussion
A regional protocol promoting thrombolysis substantially increased thrombolysis utilisation and improved overall timely reperfusion among STEMI patients transferred from outside Dublin. Persistent geographical disparities support further optimisation of regional pathways and consideration of prehospital thrombolysis strategies.