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.

Background Septal myectomy is the gold standard treatment for drug-refractory obstructive hypertrophic cardiomyopathy (oHCM). However, conventional septal myectomy (CSM) has been largely confined to specialized centers owing to its technical complexity. Transapical beating-heart septal myectomy (TA-BSM) can simplify CSM, enabling minimally invasive tailored septal resections in the beating heart under real-time echocardiographic guidance. Despite single-institution experience showed favorable efficacy and safety, whether TA-BSM can achieve similar clinical outcomes as CSM remains unknown since randomized controlled trial comparing the two approaches was unavailable. Methods The TAILOR-HCM trial (Transapical Beating-Heart Septal Myectomy versus Conventional Surgical Myectomy in Patients with Obstructive Hypertrophic Cardiomyopathy) is a multicenter, randomized, controlled, assessor-blinded, noninferiority trial evaluating the safety and efficacy of a novel device-based TA-BSM procedure conducted at 11 experienced CSM centers in China. In total, 216 symptomatic patients with oHCM who meet guideline-directed indications for septal myectomy will be randomly assigned in a 1:1 ratio to TA-BSM or CSM. The primary endpoint is relief of left ventricular outflow tract (LVOT) obstruction at 12 months, defined as a resting LVOT gradient <30 mm Hg and a standardized Valsalva maneuver-provoked LVOT gradient <50 mm Hg. Secondary endpoints include cardiac hemodynamic and structural parameters, procedure-related outcomes, quality of life, and laboratory examinations. The key safety outcome is all-cause mortality within 12 months after surgery. Conclusions TAILOR-HCM is the first multicenter randomized controlled trial evaluating both TA-BSM and CSM in oHCM. Through comparative evidence against CSM, this study will inform future clinical decision-making. If noninferior hemodynamic efficacy with favorable safety is confirmed, TA-BSM may represent an alternative surgical approach that expands therapeutic options and improves access to definitive septal reduction therapy for patients with oHCM.