## Clinical Context This patient presents with acute inferior wall STEMI (ST elevation in II, III, aVF with reciprocal changes) within the 2-hour window. The distance to a PCI-capable centre (180 km, 4-hour transfer) exceeds the acceptable door-to-balloon time. ## Reperfusion Strategy in STEMI **Key Point:** In STEMI, the goal is reperfusion within 12 hours of symptom onset. When PCI cannot be performed within 120 minutes of first medical contact (FMC), thrombolytic therapy is the standard of care. **High-Yield:** The 2010 ACC/AHA guidelines recommend: - **Primary PCI:** door-to-balloon time <90 minutes (or <120 minutes if transfer required) - **Fibrinolysis:** door-to-needle time <30 minutes if PCI not available within 120 minutes ## Why Thrombolysis Here? 1. **Time constraint:** 4-hour transfer exceeds the 120-minute window for PCI-capable centre transfer 2. **Symptom onset:** Patient is within 2 hours (fibrinolysis effective up to 12 hours, but benefit greatest in first 3 hours) 3. **Inferior STEMI:** Responds well to thrombolysis; risk of mechanical complications is lower than anterior STEMI 4. **Streptokinase:** Appropriate choice in resource-limited settings (cost-effective, no need for prior exposure) ## Dual Antiplatelet Therapy **Clinical Pearl:** Aspirin (300–325 mg loading) + clopidogrel (600 mg loading) should be given immediately alongside thrombolytic therapy. This combination reduces reinfarction and improves outcomes. ## Adjunctive Therapy | Agent | Dose | Rationale | |-------|------|----------| | Aspirin | 300–325 mg | Antiplatelet; reduce stent thrombosis | | Clopidogrel | 600 mg | P2Y12 inhibitor; synergistic with aspirin | | Streptokinase | 1.5 MU IV over 60 min | Fibrinolytic; cost-effective | | Unfractionated heparin | 60 U/kg bolus, then infusion | Anticoagulation; reduce reocclusion | **Warning:** Do NOT delay thrombolysis while awaiting transfer. Door-to-needle time is critical. 
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