A 62-year-old man presents with 2 hours of chest pain. ECG shows 3 mm ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. He arrives at a hospital without PCI capability. Door-to-balloon time via transfer would be 3.5 hours. Per current ACC/AHA STEMI guidelines, the preferred reperfusion strategy is:
- A Immediate fibrinolysis followed by transfer for angiography within 3–24 hours ✓
- B Urgent transfer for primary PCI despite the delay
- C Medical management alone with anticoagulation and dual antiplatelet therapy
- D Fibrinolysis only, with PCI reserved for failed reperfusion
Correct answer: A. Immediate fibrinolysis followed by transfer for angiography within 3–24 hours
Explanation
When primary PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis is preferred, provided there are no contraindications. A pharmaco-invasive strategy — fibrinolysis followed by mandatory transfer for angiography within 3–24 hours — is the current guideline-recommended approach. Transfer for delayed primary PCI (>120 min) is inferior to timely thrombolysis in this scenario.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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