Is the current treatment plan adequate for a 47-year-old male with a history of hypertension (HTN), ischemic heart disease (IHD), diabetes mellitus (DM), and dyslipidemia, presenting with anteroseptal ST-elevation myocardial infarction (STEMI) and complex medical history, who underwent thrombolysis with streptokinase and is experiencing gum bleeding?

Assessment of Current STEMI Treatment Plan

This treatment plan has critical gaps in antithrombotic therapy following thrombolysis and requires immediate optimization to reduce mortality and recurrent ischemic events.

Critical Deficiencies in Current Management

Missing Essential Post-Thrombolysis Anticoagulation

• The patient is not prescribed any anticoagulation therapy despite receiving streptokinase, which is a Class I, Level A recommendation. 1, 2
• Enoxaparin IV followed by subcutaneous administration is the preferred anticoagulant over unfractionated heparin (UFH) and should be continued until revascularization or for hospital duration up to 8 days. 1, 2
• Alternatively, UFH as a weight-adjusted IV bolus followed by infusion is acceptable if enoxaparin is unavailable. 1, 2
• Fondaparinux is specifically recommended for patients treated with streptokinase (non-fibrin-specific agent) as a Class IIa, Level B option. 2

Suboptimal P2Y12 Inhibitor Selection

• The patient is on clopidogrel 75mg, but current guidelines strongly recommend upgrading to a potent P2Y12 inhibitor (prasugrel or ticagrelor) after thrombolysis. 1
• Ticagrelor or prasugrel should be used preferentially over clopidogrel unless contraindicated, with continuation for 12 months. 1
• Given the patient's history of NSTEMI last year and current STEMI, the higher potency agents provide superior protection against recurrent ischemic events. 1

Mandatory Post-Thrombolysis Angiography Not Scheduled

• Transfer to a PCI-capable center following fibrinolysis is indicated in all patients immediately after thrombolysis (Class I, Level A). 1
• Angiography and PCI of the infarct-related artery should be performed between 2-24 hours after successful fibrinolysis. 1
• The plan lists "Book angio" but does not specify the critical 2-24 hour timeframe, which is essential for optimal outcomes. 1
• Emergency angiography is required immediately if there is evidence of failed thrombolysis (<50% ST-segment resolution at 60-90 minutes), hemodynamic instability, or worsening ischemia. 1

Appropriate Elements of Current Plan

Antiplatelet Therapy

• Aspirin 100mg daily is correctly prescribed (Class I, Level B recommendation). 1
• The dose is appropriate at 75-100mg for long-term maintenance. 1

Beta-Blocker Therapy

• A beta-blocker should be added to this patient's regimen, as it is indicated for patients with heart failure and/or reduced LVEF after STEMI. 1
• The patient is not currently on a beta-blocker despite having anteroseptal STEMI with likely LV dysfunction. 1

Statin Therapy

• Atorvastatin 80mg is appropriately prescribed as high-intensity statin therapy (Class I recommendation). 1
• This should be continued long-term for secondary prevention. 1

ACE Inhibitor Therapy

• Enalapril 20mg BD is appropriate and should be titrated to optimal doses during follow-up. 1

Proton Pump Inhibitor

• Omeprazole 40mg BD is correctly prescribed given the high risk of gastrointestinal bleeding with dual antiplatelet therapy (Class I, Level B). 1

Bleeding Complication Management

Gum Bleeding After Streptokinase

• The gum bleeding that led to stopping the streptokinase infusion represents a common minor bleeding complication. 2
• Despite this bleeding, anticoagulation therapy remains mandatory and should not be withheld unless there is major bleeding. 1, 2
• Gum bleeding is not a contraindication to continuing anticoagulation with careful monitoring. 1
• The coagulation parameters (INR 1.0, aPTT 29.2) are within normal range, supporting the safety of anticoagulation. 2

Additional Critical Interventions Required

Serial ECG Monitoring

• Serial ECGs should be performed at 60-90 minutes post-thrombolysis to assess for ST-segment resolution (>50% indicates successful reperfusion). 1
• This is essential to determine if rescue PCI is needed. 1

Smoking Cessation

• The patient smokes 3-4 cigarette rolls daily for >20 years, and intensive smoking cessation counseling with pharmacotherapy (varenicline or bupropion) is a Class I, Level A recommendation. 1
• This should include repeated advice, follow-up support, and nicotine replacement therapy. 1

Cardiac Rehabilitation

• Participation in a cardiac rehabilitation program is a Class I, Level A recommendation and should be arranged before discharge. 1
• This is particularly important given the patient's multiple modifiable risk factors (smoking, diabetes, hypertension, dyslipidemia). 1

Recommended Immediate Actions

1. Initiate anticoagulation immediately: Start enoxaparin 1mg/kg subcutaneously every 12 hours (preferred) or UFH infusion with weight-adjusted dosing. 1, 2

2. Upgrade P2Y12 inhibitor: Switch from clopidogrel to ticagrelor 90mg BD or prasugrel 10mg daily (if no contraindications such as age >75 years or weight <60kg). 1

3. Schedule urgent angiography: Arrange coronary angiography within 2-24 hours of thrombolysis completion, not as a delayed outpatient procedure. 1

4. Add beta-blocker: Initiate a beta-blocker (e.g., metoprolol or carvedilol) once hemodynamically stable. 1

5. Perform serial ECGs: Obtain ECG at 60-90 minutes post-thrombolysis to assess reperfusion success. 1

6. Intensive smoking cessation: Initiate pharmacotherapy and counseling immediately. 1