What is the management approach for a patient with acute cerebrovascular accident (CVA) and ST-elevation myocardial infarction (STEMI) if percutaneous coronary intervention (PCI) is not done?

Management of STEMI When PCI is Not Performed

If PCI cannot be performed for a patient with STEMI, fibrinolytic therapy should be administered immediately (within 30 minutes of first medical contact) unless contraindications exist, followed by transfer to a PCI-capable facility for angiography within 3-24 hours. 1, 2

Immediate Reperfusion Decision

When PCI is unavailable or cannot be performed within 120 minutes of STEMI diagnosis, the management pathway shifts to pharmacological reperfusion:

• Administer fibrinolytic therapy within 10 minutes of STEMI diagnosis if the patient presents within 12 hours of symptom onset and has no contraindications 1
• Use fibrin-specific agents (alteplase, tenecteplase, or reteplase) rather than streptokinase for superior outcomes 2, 3
• For patients ≥75 years old, use half-dose fibrinolytic therapy to reduce bleeding risk 3

The critical time windows are: fibrinolysis preferred if PCI delay >120 minutes for presentations within 12 hours, with every 30-minute delay increasing mortality 1, 2

Absolute Contraindications to Screen Before Fibrinolysis

Before administering fibrinolytic therapy, rapidly exclude:

• Active bleeding or bleeding diathesis 2
• History of intracranial hemorrhage or any stroke 2
• Recent major surgery or trauma within 3 weeks 2
• Suspected aortic dissection 2

Adjunctive Pharmacotherapy

Antiplatelet regimen:

• Aspirin 162-325 mg immediately (chewed or IV) 1, 2, 4
• Clopidogrel 300 mg loading dose (anticipating subsequent PCI) 1, 2
• Continue dual antiplatelet therapy for at least 14 days if no stent, or longer if PCI performed later 1

Anticoagulation:

• Enoxaparin is preferred over unfractionated heparin 1, 2
• If using unfractionated heparin, dose by weight and monitor activated clotting time 1
• Continue anticoagulation during transfer and until angiography 2

Additional medical therapy:

• Beta-blockers should be initiated orally within 24 hours if no contraindications 4
• ACE inhibitors within 24 hours, particularly for anterior MI, heart failure, or ejection fraction ≤0.40 4

The Pharmaco-Invasive Strategy

This is the modern standard of care when PCI is not immediately available:

• Initiate transfer arrangements immediately during or right after fibrinolytic administration, without waiting to assess fibrinolysis success 2
• Routine angiography should be performed within 3-24 hours after fibrinolysis, regardless of apparent clinical success 1, 2
• This combined strategy (fibrinolysis followed by routine early angiography) achieves outcomes comparable to primary PCI when executed properly 2

The European Society of Cardiology strongly endorses this approach over the older "ischemia-guided" strategy of waiting for recurrent symptoms 1, 2

Monitoring for Reperfusion Success

At 60-90 minutes post-fibrinolysis, assess ST-segment resolution:

• <50% ST-segment resolution indicates failed reperfusion and necessitates immediate rescue PCI if transfer can be expedited 2
• ≥50% ST-segment resolution suggests successful reperfusion, but routine angiography within 3-24 hours remains indicated 2
• Monitor continuously for at least 24 hours for arrhythmias and hemodynamic instability 1

Transfer Protocol

All STEMI patients who receive fibrinolysis must be transferred to a PCI-capable facility:

• Transfer should bypass the emergency department and go directly to the catheterization laboratory when angiography is planned 1
• High-risk patients (extensive ST-elevation, new left bundle branch block, anterior MI with ≥2mm ST elevation, Killip class II-III, or ejection fraction ≤35%) should be transferred as soon as possible for early angiography 1, 2
• Maintain appropriate antithrombotic therapy during transfer based on bleeding risk 5
• Communicate clearly with the receiving facility about fibrinolytic agent used, time of administration, and clinical response 5

Special Circumstances

For patients with cardiogenic shock:

• Fibrinolytic therapy is still recommended if there are no absolute contraindications and PCI cannot be performed 5
• Emergency transfer to a facility capable of PCI and coronary artery bypass graft surgery is critical 1
• Consider intra-aortic balloon pump to improve coronary perfusion while minimizing antithrombotic therapy 5, 4

For patients presenting >12 hours after symptom onset:

• Routine PCI of an occluded infarct-related artery >48 hours after STEMI onset in asymptomatic patients is not indicated 1
• However, if there is ongoing ischemia (persistent chest pain, ST-elevation, or hemodynamic instability), proceed with reperfusion strategy regardless of time from symptom onset 1

Critical Pitfalls to Avoid

• Never delay fibrinolysis while arranging transfer - every 30-minute delay increases mortality 2
• Never perform immediate PCI after fibrinolysis (facilitated PCI) - this increases bleeding and ischemic complications without mortality benefit 1, 2
• Never keep patients at the non-PCI facility for prolonged observation after fibrinolysis - transfer should be arranged immediately with angiography planned within 3-24 hours regardless of clinical stability 2
• Never use full-dose fibrinolysis followed immediately by PCI - this strategy may be harmful 1

Subsequent Management After Transfer

Once at a PCI-capable facility:

• Coronary angiography within 24 hours is recommended for patients who received fibrinolysis, even if clinically stable 5, 2
• Treatment of severe stenosis in the infarct-related artery should be performed during this angiography or staged before hospital discharge 1
• If bare-metal stents are used, dual antiplatelet therapy for at least one month; if drug-eluting stents, continue for one year 1, 5