A 58-year-old male presents to the ED with chest pains. He is afebrile with a heart rate of 70 beats per minute, blood pressure 130/90 mm Hg, respirations 20 per minute. He is given appropriate therapy with aspirin, clopidogrel, unfractionated heparin and a beta-blocker. His ECG is below:
The nearest hospital capable of percutaneous coronary intervention is 80 minutes away. Which of the following is the most appropriate course of action?
A. Immediate transfer for primary PCI
B. Administration of a direct thrombin inhibitor
C. Administration of fibrinolytic therapy
D. Administration of fibrinolytic therapy and transfer for PCI (facilitated PCI)
The decision regarding primary PCI vs. fibrinolytic therapy is important. Many major medical facilities have PCI capabilities because this is the treatment of choice for STEMI. However, smaller hospitals or those located in rural areas may not. Those facilities frequently have capabilities to quickly transfer patients experiencing a STEMI to a primary PCI facility. When there is no primary PCI available and transfer to a primary PCI facility is not able to be done in a timely fashion ― that is, transfer in less than 60 minutes ― fibrinolytic therapy is indicated.
Facilitated PCI refers to using fibrinolytic therapy to stabilize the patient while transport to a primary PCI facility is being arranged. This strategy receives a class IIb indication for high-risk patients with a low bleeding risk when primary PCI is not readily available. The patient in this case does not have any high-risk features (i.e. arrhythmia, shock, continued chest pains).