A 65-year-old man presents 2 hours after sudden severe chest pain with diaphoresis. ECG shows ST elevation in V1–V4 with reciprocal changes in II, III, aVF. He arrives at a hospital without PCI capability. Door-to-balloon time if transferred would be 110 minutes. Door-to-needle time for thrombolysis would be 25 minutes. What is the most appropriate reperfusion strategy?

• A Immediate transfer for primary PCI
• B Medical management with heparin and aspirin only
• C Emergency CABG
• D Fibrinolysis followed by transfer for angiography within 3–24 hours ✓

Explanation

When door-to-balloon time exceeds 120 minutes and symptoms are <12 hours, fibrinolysis (pharmacoinvasive strategy) is preferred over primary PCI. Current guidelines recommend fibrinolysis when PCI-related delay (door-to-balloon minus door-to-needle time) exceeds 60 minutes. After successful lysis, routine early angiography within 3–24 hours (not immediate rescue PCI unless failed lysis) is the pharmacoinvasive approach. Emergency CABG has no role as primary reperfusion.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.