A 65-year-old man presents 90 minutes after STEMI onset. Primary PCI is not achievable within 120 minutes. He receives tenecteplase. At 90 minutes post-thrombolysis, his ST segments have resolved >50% and he is pain-free. Per current ESC/ACC guidelines, what is the next best step?

• A Coronary angiography only if recurrent ischemia occurs
• B Coronary angiography within 3–24 hours (pharmacoinvasive strategy) ✓
• C Repeat thrombolysis if ECG fails to normalize at 24 hours
• D Discharge with stress testing at 6 weeks

Explanation

Successful thrombolysis (defined as >50% ST resolution at 60–90 minutes and absence of ongoing ischemia) should be followed by routine early coronary angiography within 3–24 hours as the pharmacoinvasive strategy — this is a Class I recommendation in current ESC and ACC/AHA STEMI guidelines. Delayed angiography only for recurrent ischemia (rescue PCI strategy alone) is no longer standard practice for all patients after successful lysis. Repeat thrombolysis is contraindicated after successful first administration and ineffective for failed lysis scenarios.

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

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Written and medically reviewed by the StethoPrep medical team.