A 58-year-old man with hypertension and diabetes presents with acute anterior chest pain of 2 hours duration. ECG shows ST elevation in leads V1–V4 with reciprocal ST depression in II, III, aVF. He is haemodynamically stable. Regarding the acute management of STEMI, all of the following are standard components of the reperfusion strategy EXCEPT:

Question

Accepted Answer

B. Intravenous thrombolysis as the preferred reperfusion modality in a PCI-capable centre. ## Acute STEMI Reperfusion Strategy

**Key Point:** Primary PCI is the gold standard reperfusion strategy in STEMI when performed in a PCI-capable centre within 120 minutes of first medical contact. Thrombolysis is reserved for situations where PCI cannot be performed within this window.

### Standard Components of Acute STEMI Management

| Component | Role | Timing |
|-----------|------|--------|
| Primary PCI | Gold standard reperfusion | Within 90 min (door-to-balloon) |
| Dual antiplatelet therapy | Platelet inhibition; reduces stent thrombosis | Loading before/at PCI |
| Anticoagulation (UFH/LMWH) | Prevents thrombus propagation | Acute phase, during and after PCI |
| Thrombolysis | Second-line reperfusion (if PCI unavailable) | Within 30 min if PCI delayed >120 min |

**High-Yield:** In a **PCI-capable centre**, primary PCI is always preferred over thrombolysis. Thrombolysis is NOT a standard component of acute management in such settings; it is reserved for non-PCI-capable hospitals or when PCI cannot be performed within the time window.

**Clinical Pearl:** The door-to-balloon time for primary PCI should be ≤90 minutes. If this cannot be achieved and the patient presents within 12 hours of symptom onset, thrombolysis followed by transfer for angiography is an alternative.

**Warning:** Do not confuse "thrombolysis as preferred strategy" with "thrombolysis as an option." In modern STEMI networks with PCI capability, primary PCI is preferred; thrombolysis is a fallback, not the standard first-line approach in PCI-capable centres.

### Why the Other Options Are Correct

1. **Primary PCI within 90 minutes** — Guideline-mandated reperfusion strategy in PCI-capable centres.
2. **Dual antiplatelet therapy** — Aspirin (loading 300–600 mg) + P2Y12 inhibitor (clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg) reduces stent thrombosis and recurrent ischaemic events.
3. **Anticoagulation** — UFH (bolus 70–100 U/kg, then infusion) or LMWH (enoxaparin 0.5 mg/kg IV) is mandatory to prevent thrombus extension and recurrence.

[cite:Harrison 21e Ch 297]

Answer

A. Primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact

Answer

C. Dual antiplatelet therapy (aspirin + P2Y12 inhibitor) loading before or at the time of PCI

Answer

D. Anticoagulation with unfractionated heparin or enoxaparin during the acute phase

Explanation

Acute STEMI Reperfusion Strategy

Standard Components of Acute STEMI Management

Why the Other Options Are Correct

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Component	Role	Timing
Primary PCI	Gold standard reperfusion	Within 90 min (door-to-balloon)
Dual antiplatelet therapy	Platelet inhibition; reduces stent thrombosis	Loading before/at PCI
Anticoagulation (UFH/LMWH)	Prevents thrombus propagation	Acute phase, during and after PCI
Thrombolysis	Second-line reperfusion (if PCI unavailable)	Within 30 min if PCI delayed >120 min