A 58-year-old man from Delhi presents to the emergency department with acute onset chest pain radiating to the left arm for 2 hours. His ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. His troponin I is elevated at 2.8 ng/mL (normal

Question

A 58-year-old man from Delhi presents to the emergency department with acute onset chest pain radiating to the left arm for 2 hours. His ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. His troponin I is elevated at 2.8 ng/mL (normal <0.04). Blood pressure is 95/60 mmHg, heart rate 58 bpm, and he is diaphoretic. What is the most appropriate immediate next step in management?

Accepted Answer

B. Administer aspirin 300 mg, clopidogrel 600 mg, and arrange emergency coronary angiography with primary PCI. ## Clinical Scenario Analysis This patient presents with **acute ST-elevation myocardial infarction (STEMI)** of the **inferior wall** (ST elevation in II, III, aVF indicates right coronary artery occlusion). The combination of acute chest pain, elevated troponin, hemodynamic compromise (hypotension, bradycardia), and diagnostic ECG changes mandates **immediate reperfusion therapy**. ## Reperfusion Strategy in STEMI **Key Point:** In a PCI-capable centre (which Delhi hospitals are), **primary PCI is the gold standard** for STEMI with a door-to-balloon time target of ≤90 minutes. This patient requires urgent coronary angiography to identify the culprit lesion and restore flow. **High-Yield:** The inferior STEMI with bradycardia and hypotension raises concern for **right ventricular (RV) infarction**. RV infarcts are **preload-dependent**; fluid resuscitation may be needed, but this does not delay PCI. ## Why Option 0 Is Correct 1. **Dual antiplatelet therapy** (aspirin + clopidogrel loading) is guideline-mandated before PCI in STEMI. 2. **Emergency coronary angiography with primary PCI** is the definitive reperfusion method in a PCI-capable hospital. 3. **Time is myocardium**: every minute of delay increases mortality and infarct size. 4. Hemodynamic instability (SBP 95 mmHg) is NOT a contraindication to PCI; it is an indication for urgent intervention. ```mermaid flowchart TD A["Acute chest pain + ST elevation in inferior leads"]:::outcome --> B{"PCI-capable hospital?"}:::decision B -->|Yes| C["Dual antiplatelet therapy
Aspirin 300 mg + Clopidogrel 600 mg"]:::action C --> D["Emergency coronary angiography"]:::action D --> E["Primary PCI to culprit artery"]:::action E --> F["Reperfusion achieved"]:::outcome B -->|No| G["Thrombolytic therapy
+ transfer for rescue PCI if failed"]:::action ``` ## Inferior STEMI with RV Involvement | Feature | Inferior STEMI | RV Infarction (Complication) | |---------|---|---| | **ST elevation** | II, III, aVF | Also in V4R (right-sided ECG) | | **Hemodynamics** | Normal or mild ↓ BP | Marked ↓ BP, ↑ JVP (preload-dependent) | | **Management** | Standard PCI + fluids as needed | **Avoid nitrates**; fluid resuscitation; PCI still indicated | | **Bradycardia** | Common (vagal) | Common (RV ischemia) | **Clinical Pearl:** Do NOT delay PCI to obtain a right-sided ECG (V4R) in suspected RV infarction. The diagnosis is clinical (hypotension + inferior STEMI + elevated JVP), and PCI is still the definitive treatment. **Warning:** Thrombolytic therapy is slower, less effective, and carries higher re-infarction risk than primary PCI in a PCI-capable centre. It is reserved for PCI-incapable hospitals or when PCI cannot be performed within 120 minutes of first medical contact. ![ECG — Waves and Intervals diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/3696.webp)

Answer

A. Start intravenous heparin, observe for 6 hours, and perform stress testing if symptoms resolve

Answer

C. Obtain a repeat ECG in 15 minutes and measure serial troponins before deciding on intervention

Answer

D. Administer thrombolytic therapy (streptokinase) and defer angiography to day 3

Explanation

Clinical Scenario Analysis

Reperfusion Strategy in STEMI

Why Option 0 Is Correct

Inferior STEMI with RV Involvement

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Feature	Inferior STEMI	RV Infarction (Complication)
ST elevation	II, III, aVF	Also in V4R (right-sided ECG)
Hemodynamics	Normal or mild ↓ BP	Marked ↓ BP, ↑ JVP (preload-dependent)
Management	Standard PCI + fluids as needed	Avoid nitrates; fluid resuscitation; PCI still indicated
Bradycardia	Common (vagal)	Common (RV ischemia)