A 58-year-old man with a history of hypertension presents to the emergency department with acute chest pain radiating to the left arm for 30 minutes. His vital signs are stable. A 12-lead ECG is obtained and shows ST-segment elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. Troponin I is elevated at 2.8 ng/mL (normal <0.04). What is the most appropriate immediate next step in management?

Explanation

## Clinical Presentation & ECG Findings This patient presents with acute ST-elevation myocardial infarction (STEMI) in the inferior wall (ST elevation in II, III, aVF). The combination of: - Acute chest pain <30 minutes duration - ST-segment elevation ≥1 mm in ≥2 contiguous leads - Elevated troponin - Reciprocal ST depression confirms acute transmural myocardial infarction requiring urgent revascularization. ## Management Algorithm for STEMI ```mermaid flowchart TD A[STEMI Diagnosis Confirmed]:::outcome --> B{PCI-Capable Hospital?}:::decision B -->|Yes| C[Dual Antiplatelet Therapy:<br/>Aspirin + P2Y12 Inhibitor]:::action C --> D[Primary PCI<br/>Within 90 minutes]:::action D --> E[Reperfusion Achieved]:::outcome B -->|No| F[Thrombolysis<br/>Within 30 minutes]:::action F --> G{Reperfusion Success?}:::decision G -->|Yes| H[Arrange Transfer for<br/>Angiography]:::action G -->|No| I[Rescue PCI]:::urgent ``` ## Key Point: **Primary percutaneous coronary intervention (PCI) is the gold standard for STEMI management** when performed in a PCI-capable facility within 90 minutes of first medical contact (door-to-balloon time). Dual antiplatelet therapy (aspirin + P2Y12 inhibitor like clopidogrel) must be initiated immediately before or at the time of angiography [cite:Harrison 21e Ch 297]. ## Why This Option Is Correct **Aspirin 300 mg + clopidogrel 600 mg + urgent PCI** represents the evidence-based, guideline-recommended approach: 1. **Dual antiplatelet therapy** reduces stent thrombosis and recurrent ischemic events 2. **Primary PCI** has superior outcomes compared to thrombolysis (lower mortality, fewer reinfarctions, fewer strokes) 3. **Time-sensitive intervention** — every minute of delay increases myocardial necrosis 4. **Inferior STEMI** often involves right ventricular involvement; primary PCI allows assessment and selective intervention ## High-Yield: **Door-to-balloon time <90 minutes** is the target for primary PCI in STEMI. If door-to-balloon time would exceed 120 minutes AND door-to-needle time for thrombolysis is <30 minutes, thrombolysis may be considered as an alternative, but PCI remains superior when feasible [cite:Harrison 21e Ch 297].