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Acute ST-segment elevation myocardial infarction — MRCEM SBA MCQ

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EasyCardiovascular emergenciesAcute ST-segment elevation myocardial infarctionMRCEM SBA

A 58-year-old man presents to an emergency department without on-site PCI, 2 hours after the onset of persistent central chest pain. His ECG shows 3 mm ST-segment elevation in leads II, III and aVF, with reciprocal ST-segment depression in aVL. He has received 300 mg aspirin. He is alert, his blood pressure is 132/78 mmHg, and assessment identifies no contraindication to fibrinolysis. The PCI centre estimates that primary PCI could be delivered 160 minutes after fibrinolysis could be started here. What is the most appropriate immediate reperfusion plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Give fibrinolysis with concomitant antithrombin

The persistent pain and diagnostic ST-segment elevation identify an acute STEMI requiring prompt reperfusion. He is within 12 hours of symptom onset, has no identified contraindication to fibrinolysis and is not in cardiogenic shock. NICE recommends fibrinolysis when primary PCI cannot be delivered within 120 minutes of the time fibrinolysis could have been given; here, the estimated interval is 160 minutes. An antithrombin should be given at the same time as fibrinolysis. ([nice.org.uk](https://www.nice.org.uk/guidance/NG185/chapter/recommendations)) Transfer for primary PCI without fibrinolysis (A) would be preferred if PCI could meet the 120-minute criterion, but it cannot here. Repeating the ECG before treatment (B) could help if the first tracing were nondiagnostic; this one already establishes STEMI. Angiography within 72 hours without immediate reperfusion (D) delays treatment of an eligible STEMI. Troponin testing (E) must not postpone reperfusion when the ECG is diagnostic. After fibrinolysis, obtain an ECG at 60–90 minutes and arrange immediate angiography, with PCI if indicated, if persistent ST elevation suggests failed reperfusion. ([nice.org.uk](https://www.nice.org.uk/guidance/NG185/chapter/recommendations))

Reference: NICE NG185: Acute coronary syndromes — recommendations 1.1.6 and 1.1.19 (18 November 2020) — https://www.nice.org.uk/guidance/NG185/chapter/recommendations NICE NG185: Acute coronary syndromes — recommendation 1.1.20 (18 November 2020) — https://www.nice.org.uk/guidance/NG185/chapter/recommendations NICE NG185: Acute coronary syndromes — recommendation 1.1.21 (18 November 2020) — https://www.nice.org.uk/guidance/NG185/chapter/recommendations