A 55-year-old construction worker is brought to the emergency department 2 hours after awakening with severe left chest discomfort. He appears diaphoretic and uncomfortable. He has no other medical problems and has not seen a physician in 5 years.
His blood pressure is 152/88 mm Hg and pulse is 92/min. Examination shows clear lung fields, normal first and second heart sounds, and the presence of a fourth heart sound. His initial EKG shows sinus rhythm with a 3-mm ST-segment elevation in leads V1-V4.
The hospital does not have a cardiac catheterization laboratory and the closest hospital with angioplasty capabilities is 2 hours away. The patient is given a single bolus dose of tenecteplase over 10 seconds. His chest discomfort subsides completely, and a repeat EKG 30 minutes after injection shows near-complete resolution of the ST-segment elevation.
Which of the following is the best next step in managing this patient?

Question

A 55-year-old construction worker is brought to the emergency department 2 hours after awakening with severe left chest discomfort.  He appears diaphoretic and uncomfortable.  He has no other medical problems and has not seen a physician in 5 years.
His blood pressure is 152/88 mm Hg and pulse is 92/min.  Examination shows clear lung fields, normal first and second heart sounds, and the presence of a fourth heart sound.  His initial EKG shows sinus rhythm with a 3-mm ST-segment elevation in leads V1-V4.
The hospital does not have a cardiac catheterization laboratory and the closest hospital with angioplasty capabilities is 2 hours away.  The patient is given a single bolus dose of tenecteplase over 10 seconds.  His chest discomfort subsides completely, and a repeat EKG 30 minutes after injection shows near-complete resolution of the ST-segment elevation.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Primary percutaneous coronary intervention (PCI) is the preferred treatment for acute ST-elevation myocardial infarction due to its significant reduction in mortality, reinfarction, and complications compared to fibrinolysis. However, due to the limited availability of PCI therapy in some locations, fibrinolysis remains an alternate therapy of choice. Despite successful reperfusion with fibrinolysis, reocclusion can occur in about 20%-30% of patients. As a result, all patients who have received fibrinolytic therapy should be transferred to a PCI-capable hospital as soon as possible for further treatment due to the possibility of reocclusion over the next several hours (Choices A, B, D, and E). Educational objective: Reocclusion can develop in about 20%-30% of patients with acute ST-elevation myocardial infarction after initial successful reperfusion with fibrinolytic therapy. All patients who have received fibrinolytic therapy in a hospital or ambulance without capabilities for primary percutaneous coronary intervention (PCI) should be transferred immediately to a PCI-capable hospital. __________ References: Efficacy of early invasive management post-fibrinolysis in men versus women with ST-elevation myocardial infarction: A subgroup analysis from Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI). (http://www.ncbi.nlm.nih.gov/pubmed/22980300) Optimal selection of STEMI treatment strategies in the current era: benefit of transferring STEMI patients for PCI compared with administration of onsite fibrinolytic therapy. (http://www.ncbi.nlm.nih.gov/pubmed/23032713)

A 55-Year-Old Construction Worker Is Brought to the Emergency Department