A 63-year-old man presents to the emergency department 90 minutes after the sudden onset of severe substernal chest pressure. The pain began while he was shoveling dirt in his yard and radiates to his left arm. Associated symptoms include nausea, diaphoresis, and shortness of breath. His medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. Medications include metformin, atorvastatin, and lisinopril. Temperature is 36.9°C (98.4°F), blood pressure is 146/88 mm Hg, pulse is 102/min, respiratory rate is 20/min, and oxygen saturation is 97% on room air. On physical examination, e appears uncomfortable and diaphoretic and is mildly tachycardic. ECG demonstrates 2-mm ST-segment elevations in leads V2-V5. Initial troponin level is elevated. A hospital with 24-hour cardiac catheterization capability is available and can perform percutaneous coronary intervention within 60 minutes.
Which of the following is the most appropriate next step in management?
The correct answer is:
C) Emergent coronary angiography with percutaneous coronary intervention
This patient has an acute ST elevation myocardial infarction (STEMI), demonstrated by characteristic ischemic chest pain, elevated cardiac biomarkers, and ST-segment elevation in contiguous anterior leads. The most important management priority is rapid restoration of coronary blood flow through reperfusion therapy.
Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy when it can be performed promptly by an experienced team. Compared with fibrinolytic therapy, PCI achieves higher rates of coronary reperfusion and is associated with lower rates of recurrent ischemia, reinfarction, intracranial hemorrhage, and death. Because PCI can be performed within 60 minutes in this patient, immediate cardiac catheterization is indicated.
A high-yield Step 2 principle is that treatment decisions in STEMI are driven by time to reperfusion. When timely PCI is available, PCI is preferred. Fibrinolytic therapy is generally reserved for situations in which PCI cannot be performed within an acceptable timeframe and there are no contraindications to thrombolysis.
In addition to reperfusion, patients should receive evidence-based medical therapy including aspirin, a P2Y12 inhibitor, anticoagulation, statin therapy, and other supportive measures as indicated. However, none of these interventions replaces the need for immediate reperfusion.
Answer choice A: Administer fibrinolytic therapy immediately, is incorrect.
Fibrinolytic therapy is an important reperfusion option when timely PCI is unavailable. However, when PCI can be performed rapidly, primary PCI is preferred because it provides superior outcomes and lower complication rates.
Answer choice B: Admit for observation and repeat troponin testing in 6 hours, is incorrect.
Observation may be appropriate for selected low-risk chest pain presentations, but it is inappropriate for a patient with diagnostic ECG findings of STEMI. Delaying reperfusion would allow ongoing myocardial necrosis.
Answer choice D: Exercise stress testing before deciding on treatment, is incorrect.
Stress testing is contraindicated in patients with acute myocardial infarction and active ischemia. The diagnosis of STEMI has already been established, and immediate treatment is required.
Answer choice E: Initiate aspirin therapy and schedule outpatient cardiology follow-up, is incorrect.
Aspirin should be administered immediately, but outpatient management would be dangerous in a patient with STEMI. Urgent reperfusion therapy is necessary to minimize infarct size and reduce mortality.
Key Learning Point
Patients with STEMI require immediate reperfusion therapy. When timely percutaneous coronary intervention is available, primary PCI is preferred over fibrinolytic therapy because it improves outcomes and reduces complications.
