A 58-year-old man with hypertension presents to the emergency department with acute onset chest pain radiating to the left arm. His vital signs are stable. The 12-lead ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. What is the most appropriate immediate next step in management?

Explanation

## Clinical Scenario Analysis This patient presents with **acute ST-elevation myocardial infarction (STEMI)** of the **inferior wall** (ST elevation in II, III, aVF with reciprocal changes in I, aVL). ## Pathophysiology Inferior STEMI typically results from **right coronary artery (RCA) occlusion** (85% of cases). The ST elevation indicates **acute transmural myocardial necrosis** with ongoing myocardial injury — time-sensitive intervention is critical to salvage viable myocardium. ## Management Algorithm ```mermaid flowchart TD A[STEMI Diagnosis on ECG]:::outcome --> B{Time since symptom onset?}:::decision B -->|< 12 hours| C[PCI-capable facility available?]:::decision C -->|Yes| D[Dual antiplatelet therapy + Primary PCI within 90 min]:::action C -->|No| E[Fibrinolytic therapy + Transfer for rescue PCI]:::action B -->|> 12 hours, stable| F[Dual antiplatelet + Coronary angiography within 24 hrs]:::action D --> G[Reperfusion & Risk Stratification]:::outcome ``` ## Key Point: **Primary PCI is the gold standard for STEMI management** when performed within 120 minutes of first medical contact (FMC). In this case, the patient is within the therapeutic window and dual antiplatelet therapy (aspirin + P2Y₁₂ inhibitor) must be initiated immediately before PCI. ## High-Yield Facts | Intervention | Timing | Evidence | |---|---|---| | **Dual antiplatelet therapy** | Immediately (pre-PCI) | Reduces stent thrombosis & mortality | | **Primary PCI** | Within 90 min of FMC (120 min acceptable) | Superior to fibrinolysis; reduces reinfarction | | **Fibrinolysis** | If PCI unavailable; within 30 min of FMC | Backup strategy; higher reinfarction risk | ## Clinical Pearl: **Inferior STEMI with RV involvement** (look for ST elevation in V4R) requires careful fluid management — avoid aggressive diuresis as RV infarction is preload-dependent. However, this does not change the acute reperfusion strategy. ## Warning: ~~Troponin and repeat ECG are diagnostic tools, not therapeutic interventions~~ — in acute STEMI, diagnosis is already established by ECG; time must not be wasted on confirmatory testing. The mantra is "time is myocardium." [cite:Harrison 21e Ch 297]