A 58-year-old man with diabetes and hypertension presents to the emergency department with acute chest pain of 2 hours duration, diaphoresis, and dyspnea. His BP is 145/92 mmHg, HR 102/min. ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. Troponin I is 0.8 ng/mL (normal <0.04). The hospital has PCI capability with a door-to-balloon time achievable within 90 minutes. What is the most appropriate immediate next step in management?

## Clinical Scenario Analysis This patient presents with **acute STEMI** (ST-elevation myocardial infarction) meeting all diagnostic criteria: - Acute chest pain <12 hours from symptom onset - ST elevation in anatomically contiguous leads (inferior wall: II, III, aVF) - Elevated cardiac biomarkers (troponin I) - Hemodynamic stress (tachycardia, hypertension) ## Reperfusion Strategy Selection **Key Point:** Primary PCI is the gold-standard reperfusion modality for STEMI when door-to-balloon time is ≤90 minutes [cite:Harrison 21e Ch 297]. In this case: - Door-to-balloon time achievable within 90 minutes ✓ - PCI-capable facility available ✓ - No contraindications to PCI mentioned ## Immediate Management Steps **High-Yield:** Dual antiplatelet therapy (DAPT) + primary PCI is the standard of care for STEMI with PCI capability. | Step | Action | Rationale | |------|--------|----------| | 1 | Dual antiplatelet therapy | Aspirin 325 mg (loading) + P2Y12 inhibitor (clopidogrel 600 mg loading or prasugrel 60 mg or ticagrelor 180 mg) | | 2 | Prepare for emergent PCI | Activate cath lab, arrange transport | | 3 | Adjunctive anticoagulation | Unfractionated heparin or enoxaparin during procedure | | 4 | Beta-blocker (if no contraindication) | Reduce myocardial oxygen demand | **Clinical Pearl:** The time from door-to-balloon should not exceed 90 minutes for primary PCI in STEMI. Every minute of delay increases mortality; therefore, parallel processing (ECG → DAPT initiation → cath lab activation) is essential. ## Why Primary PCI Over Thrombolysis? ```mermaid flowchart TD A[STEMI Diagnosis]:::outcome --> B{PCI-capable hospital<br/>& door-to-balloon ≤90 min?}:::decision B -->|Yes| C[Primary PCI + DAPT]:::action B -->|No| D{Symptom onset<br/>< 12 hours?}:::decision D -->|Yes| E[Thrombolysis]:::action D -->|No| F[Medical management<br/>+ risk stratification]:::action C --> G[Superior outcomes:<br/>Lower re-infarction,<br/>lower mortality]:::outcome E --> H[Higher re-infarction rate<br/>if failed lysis]:::outcome ``` **Key Point:** Primary PCI has superior outcomes compared to fibrinolysis: lower 30-day mortality, lower re-infarction rate, and lower intracranial hemorrhage risk [cite:Harrison 21e Ch 297].