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STEMI — USMLE Step 3 MCQ

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HardEmergency MedicineSTEMIUSMLE Step 3

A 63-year-old man with inferior STEMI becomes hypotensive after sublingual nitroglycerin. He has jugular venous distention, clear lungs, and ST elevation in V4R. What is the best immediate management while arranging reperfusion?

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Correct answer: D — Stop nitrates, give cautious IV crystalloid, and proceed to reperfusion

The best answer is “Stop nitrates, give cautious IV crystalloid, and proceed to reperfusion”. Right-ventricular infarction causes preload-dependent output. Nitrates worsen hypotension; cautious volume loading supports preload while urgent reperfusion proceeds. Right-ventricular infarction is preload dependent; hypotension after nitrates is treated with volume support and urgent reperfusion.

Reference: 2025 ACC/AHA Acute Coronary Syndromes Guideline: https://www.acc.org/Guidelines/Guidelines/2025/02/27/21/01/ACS