Reconsidering fibrinolysis in selected patients with non–ST-elevation acute coronary syndrome: A hypothesis-generating, research-based framework

For decades, the use of fibrinolytic agents in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) has been contraindicated by major clinical guidelines, mainly due to the lack of demonstrated benefit and the risk of bleeding. However, recent diagnostic advances, particularly the application of artificial intelligence to electrocardiography, now allow identification of subgroups of patients without ST-segment elevation who in fact present with acute coronary artery occlusion and may therefore require immediate reperfusion. This article weighs the potential risks and benefits of fibrinolytic therapy in NSTE-ACS and proposes specific lines of research and clinical criteria to assess the selective, research-based exploration of fibrinolysis in these patients. Specifically, this exploration concerns selected NSTE-ACS patients in whom timely angiographic evaluation or percutaneous coronary intervention (PCI) is unavailable. This article does not propose a change in clinical practice. Instead, it outlines a hypothesis-generating, research-based framework to explore whether, in highly selected circumstances and in the absence of timely PCI, fibrinolytic therapy could be studied in NSTE-ACS patients with probable acute coronary occlusion identified by advanced diagnostic tools.