Inferior STEMI at a non-PCI centre — case discussion

Objectives

1. Choose between primary PCI and fibrinolysis using the 2023 ESC and 2025 ACC/AHA time limits. ^[1][2]
2. Recognise right-ventricular involvement before giving preload-reducing drugs. ^[30]
3. Run the pharmaco-invasive pathway after fibrinolysis. ^[1]

Candidate brief

Practice case discussion; this is not a real patient. You are the cardiologist taking the call from the rural doctor. In 15 minutes, give the reperfusion plan from first medical contact to angiography. Then say what you would do if his blood pressure falls. ^[1]

Expected actions

• Confirm the diagnosis. New 3 mm J-point elevation in II, III and aVF meets the ESC 2023 criterion of new J-point ST elevation of 1 mm or more in at least two contiguous leads outside V2–V3, in the absence of LV hypertrophy or LBBB.^[1]
• Do the time arithmetic. ESC 2023 prefers primary PCI provided it can be done within 120 min of the ECG-based diagnosis.^[1] The retrieval estimate here is about 150 minutes, so give immediate fibrinolysis and transfer without waiting for signs of reperfusion.^[1] ACC/AHA 2025 reaches the same choice: at a non-PCI-capable hospital, transfer for primary PCI is recommended if device activation can reasonably be predicted within 2 hours of FMC; if not, and symptoms began under 12 hours ago, fibrinolysis is recommended.^[2]
• Check contraindications. Use the ACC/AHA 2025 list, for example prior intracranial haemorrhage, suspected aortic dissection, active bleeding, and severe uncontrolled hypertension unresponsive to therapy (SBP over 180 or DBP over 110 mm Hg).^[2]
• Prescribe (ACC/AHA 2025 tables). Tenecteplase 45 mg for 80–89 kg. Aspirin 162–325 mg orally, chewed when possible. Clopidogrel 300 mg (age 75 or younger). Enoxaparin (age under 75): 30 mg IV bolus, then 1 mg/kg SC every 12 h from 15 min later (maximum 100 mg for the first 2 doses).^[2]
• Start fast. The ESC 2023 goal is to start fibrinolysis within 10 min of the STEMI diagnosis. Here the diagnostic ECG was recorded on arrival at 07:20, so the bolus should be given within 10 min of it.^[1] Had he called the EMS and fibrinolysis still been the reperfusion strategy, ESC 2023 recommends starting it in the prehospital setting as soon as possible after diagnosis, aiming for under 10 min to the lytic bolus (Class I, Level A), when the ECG can be interpreted on site or transmitted, and areas with long transfers should have protocols for rapid fibrinolysis at the place of diagnosis.^[1]
• Book the next step before the bolus. Transfer immediately. Rescue PCI if ST resolution is under 50% within 60–90 min, or with haemodynamic or electrical instability, worsening ischaemia or persistent chest pain. Otherwise angiography within 2–24 h.^[1] STREAM supports this strategy in patients with STEMI within 3 h of symptom onset who could not have primary PCI within 1 hour (similar 30-day composite, 12.4% vs 14.3%; RR 0.86, P=0.21).^[5][1]
• Look for the right ventricle. Record V3R and V4R in inferior STEMI.^[1] ST elevation greatest in lead III suggests RV infarction.^[30]
• If hypotension develops with features of RV infarction (hypotension with raised JVP, ST elevation in V3R/V4R).^[30][1] Stop nitrates, which should not be given in hypotension or RV infarction.^[1] Give IV fluid to support preload. Nitroglycerin and morphine may worsen RV-infarct hypotension.^[30]
• Avoid the traps. ESC 2023 finds no evidence that GP IIb/IIIa inhibitors improve perfusion or outcomes with fibrinolysis, and they may increase bleeding.^[1] ACC/AHA 2025: reperfusion should not be delayed pending biomarker results; ESC 2023 likewise says fibrinolysis should not wait for biomarker results.^[2][1]

Marking

Pass:

• Applies the 120-min ESC 2023 limit (or the ACC/AHA 2025 90/120-minute goals) and chooses fibrinolysis.^[1][2]
• Gives tenecteplase by weight band with aspirin, clopidogrel and an anticoagulant at correct doses.^[2]
• Plans immediate transfer, rescue PCI criteria and 2–24 h angiography.^[1]
• Records right-sided leads and manages RV-infarct hypotension with fluid, not nitrates.^[1][30]

Fail:

• Transfers for primary PCI despite an expected delay over 120 min, or waits for troponin.^[1][2]
• Gives repeat fibrinolysis for failed lysis.^[1]
• Gives further nitrate to a hypotensive inferior STEMI.^[1]