Examkin

Question

Difficulty: HardCardiovascular System

A 62-year-old man presents to a rural emergency department with crushing substernal chest pain that began 45 minutes ago. His blood pressure is 130/80 mmHg130/80\text{ mmHg}, and his heart rate is 88/min88/\text{min}. An electrocardiogram reveals 4 mm4\text{ mm} ST-segment elevations in leads II, III, and aVF. The hospital does not have a cardiac catheterization laboratory. The nearest percutaneous coronary intervention (PCI)-capable center is 150 minutes away by helicopter due to current weather conditions.

Arrange the following management steps in the most appropriate chronological order according to standard guidelines.

  1. 1Administer chewable aspirin and an oral P2Y12 inhibitor
  2. 2Administer an intravenous fibrinolytic agent
  3. 3Transfer the patient to a percutaneous coronary intervention (PCI)-capable facility
  4. 4Perform coronary angiography

Answer

The correct sequence begins with immediate dual antiplatelet therapy, followed by intravenous fibrinolysis (due to a transfer time >120 minutes). The patient is then transferred to a PCI-capable center, where coronary angiography is ultimately performed.
In the management of acute STEMI at a non-PCI capable facility, the critical decision point is the anticipated first medical contact-to-device time. Because the transfer time in this scenario is 150 minutes (well beyond the 120-minute threshold), the patient must receive a fibrinolytic agent within 30 minutes of arrival. Dual antiplatelet therapy is administered immediately upon presentation. After fibrinolysis, the patient is transferred to a PCI-capable center for coronary angiography (pharmacoinvasive strategy).

Step-by-Step Solution

1
Identify the diagnosis and immediate pharmacologic needs.
The patient has an acute inferior STEMI and requires immediate dual antiplatelet therapy (aspirin and a P2Y12 inhibitor).
To inhibit further platelet aggregation and prevent propagation of the coronary thrombus as early as possible.
2
Evaluate the expected time to primary percutaneous coronary intervention (PCI).
The patient is at a non-PCI capable center, and the expected transport time is 150 minutes.
The 120-minute threshold for first medical contact-to-device time determines whether primary PCI or fibrinolysis is the initial reperfusion strategy.
3
Determine the appropriate initial reperfusion strategy at the current facility.
Intravenous fibrinolytic therapy must be administered.
Because the transfer time exceeds 120 minutes, guidelines mandate administering fibrinolytics within 30 minutes of arrival to minimize total ischemic time.
4
Determine the post-fibrinolytic disposition.
Transfer the patient to a PCI-capable facility.
All patients receiving fibrinolytics require transfer for a pharmacoinvasive strategy.
5
Determine the definitive procedural management at the receiving center.
Perform coronary angiography.
To assess coronary anatomy and intervene on the culprit lesion, either immediately if lysis failed or routinely within 2-24 hours if successful.

Key Concept

Management of ST-segment elevation myocardial infarction (STEMI) at a non-PCI capable center.
Estimated Time:1m 30s
Rate this question

Topics

Cardiovascular System

More questions from this topic