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?

Explanation

## 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<br/>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<br/>+ 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.