What is the most appropriate reperfusion strategy for a patient with acute myocardial infarction (AMI) presenting with elevated troponin I and ST elevations on electrocardiogram (ECG), located at a critical access hospital far from a percutaneous coronary intervention (PCI) site?

Reperfusion Strategy for STEMI at Critical Access Hospital

For this patient with STEMI at a critical access hospital requiring prolonged transport time to PCI, the optimal strategy is fibrinolysis followed by immediate transfer for percutaneous coronary intervention, which provides the lowest morbidity and mortality. 1

Rationale for Fibrinolysis with Transfer

The 2015 International Consensus and 2013 ACC/AHA guidelines explicitly recommend emergency transfer without fibrinolysis to a PCI center when the anticipated first medical contact (FMC)-to-device time is ≤120 minutes. 1 However, when this time window cannot be achieved—as in this critical access hospital scenario—fibrinolytic therapy with routine transfer for angiography within 3-6 hours (up to 24 hours) becomes the preferred alternative strategy. 1

Time-Critical Decision Framework

• Primary PCI remains superior when FMC-to-device time is ≤90 minutes for patients at PCI-capable hospitals, or ≤120 minutes when transfer is required. 1
• When anticipated FMC-to-device time exceeds 120 minutes due to unavoidable delays, fibrinolytic therapy should be administered within 30 minutes of hospital arrival in the absence of contraindications. 1
• The European Society of Cardiology guidelines demonstrate that the "PCI-related delay" (door-to-balloon minus door-to-needle time) that negates PCI superiority ranges from 60-120 minutes, with most analyses supporting fibrinolysis when delays exceed 120 minutes. 1

Evidence Supporting Pharmacoinvasive Strategy

The pharmacoinvasive approach (fibrinolysis followed by routine early angiography) has demonstrated outcomes comparable to primary PCI when fibrinolysis is administered early and transfer occurs within 3-24 hours. 1 This strategy combines:

• Immediate reperfusion benefit from fibrinolysis 1
• Mechanical revascularization advantages through subsequent PCI 1
• Rescue PCI availability if fibrinolysis fails (defined as <50% ST-segment resolution at 60-90 minutes) 2, 3

Why Other Options Are Inferior

Transfer for PCI Only (Without Fibrinolysis)

This approach results in unacceptable delays to reperfusion, with every 30-minute delay associated with increased mortality. 1 The benefit of reperfusion therapy is greatest within the first 2-3 hours of symptom onset, and mortality reduction diminishes significantly with prolonged ischemic time. 1

Fibrinolysis Without Transfer

The 2015 guidelines explicitly recommend against fibrinolysis with monitoring in the ED without subsequent transfer. 1 After fibrinolysis, patients require transport for early routine angiography within 3-6 hours rather than only ischemia-guided angiography. 1 This approach:

• Misses the opportunity for rescue PCI if reperfusion fails 2
• Fails to address residual coronary stenosis 1
• Increases risk of reocclusion and reinfarction 1

Heparin Infusion and Transfer

Anticoagulation alone without reperfusion therapy is inadequate and results in significantly worse outcomes. 1 This patient has clear STEMI with symptoms and requires definitive reperfusion, not merely anticoagulation during transport.

Implementation Algorithm

Step 1: Immediate Fibrinolytic Administration

Administer fibrin-specific thrombolytic agent (tenecteplase preferred as single weight-adjusted bolus) within 30 minutes of hospital arrival. 2, 3, 4

• Aspirin 150-325 mg orally (chewable) or IV immediately 2, 3
• Clopidogrel 300 mg loading dose 2, 3
• Enoxaparin 30 mg IV bolus followed by 1 mg/kg subcutaneously every 12 hours 2, 3
• Tenecteplase as single weight-adjusted IV bolus (30-50 mg based on weight) 3, 4

Step 2: Arrange Immediate Transfer

Contact receiving PCI center and arrange emergency transfer during or immediately after fibrinolytic administration. 1, 3 The goal is angiography within 3-6 hours of fibrinolysis. 1

Step 3: Monitor for Reperfusion Success

Assess ST-segment resolution at 60-90 minutes post-fibrinolysis. 2

• If <50% ST-segment resolution: Rescue PCI indicated immediately upon arrival 2
• If ≥50% ST-segment resolution: Routine angiography within 3-24 hours 1

Critical Contraindications to Screen

Before administering fibrinolysis, rapidly exclude: 2, 4

• Active internal bleeding or bleeding diathesis
• History of intracranial hemorrhage or stroke
• Intracranial neoplasm, arteriovenous malformation, or aneurysm
• Recent major surgery or trauma (<3 weeks)
• Severe uncontrolled hypertension
• Suspected aortic dissection (critical in patients with chest pain and diaphoresis) 2

Important Caveats

The FDA label for tenecteplase warns against routine combination of fibrinolysis with immediate PCI, as this increases mortality (6.7% vs 4.9%), cardiogenic shock (6.3% vs 4.8%), and heart failure (12% vs 9.2%) compared to PCI alone. 4 The pharmacoinvasive strategy differs by incorporating a 2-3 hour delay before angiography, allowing fibrinolysis to work while avoiding the hazards of immediate combined therapy. 1

Fibrinolysis increases stroke risk (RR 3.57) and hemorrhagic stroke risk (RR 4.37) compared to primary PCI, but reduces cardiogenic shock (RR 0.67) and maintains equivalent mortality when administered early in the prehospital or early hospital setting. 5

This patient's anterior STEMI (V2-V4 elevations) represents a large area at risk, making time to reperfusion particularly critical for myocardial salvage and mortality reduction. 1