Chest pressure and ST-segment elevation in a 64-year-old teacher
A 64-year-old high school teacher presents to a rural emergency department with 90 minutes of substernal chest pressure that began while grading essays. Eight weeks ago, he had an ischemic stroke causing mild residual right-hand clumsiness; he takes aspirin and atorvastatin. Blood pressure is 142/86 mm Hg, pulse is 76/min, and lungs are clear to auscultation. An electrocardiogram shows 3 mm ST-segment elevation in leads V2 through V4. The facility lacks catheterization capabilities, and the nearest interventional center has an anticipated first-medical-contact to balloon-inflation time of 145 minutes. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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A
Explanation
Clinical Pearl:
When primary percutaneous coronary intervention cannot be delivered within 120 minutes in ST-elevation myocardial infarction, fibrinolysis is contraindicated if an ischemic stroke occurred within the preceding 3 months. In these patients, emergent transfer for primary percutaneous coronary intervention remains indicated regardless of the anticipated transport delay.
Explanation:
This patient has an acute anterior ST-elevation myocardial infarction, established by acute substernal chest pressure and 3 mm ST-segment elevation across leads V2 through V4. Although fibrinolytic therapy is typically administered when transfer for primary percutaneous coronary intervention cannot achieve balloon inflation within 120 minutes of medical contact, an ischemic stroke within the prior 3 months is an absolute contraindication to fibrinolysis; therefore, relevant cardiovascular society guidance dictates immediate transfer for primary percutaneous coronary intervention regardless of transport delay. Administration of intravenous tenecteplase is unsafe because fibrinolysis in the setting of recent cerebral infarction carries an unacceptably high risk of catastrophic intracranial hemorrhage. Admission to the local telemetry unit with low-molecular-weight heparin alone withholds definitive mechanical reperfusion, leading to ongoing myocardial necrosis and substantially higher mortality. Obtaining a non-contrast head computed tomography scan does not negate the contraindication of a documented stroke within 8 weeks and introduces unjustified delay in coronary reperfusion. Initiation of unfractionated heparin with elective coronary angiography within 48 hours applies to non-ST-elevation myocardial infarction or successful pharmacoinvasive pathways, whereas acute ST-elevation myocardial infarction requires immediate mechanical restoration of coronary blood flow.
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