In a 58-year-old man presenting with crushing chest pain radiating to the left arm and anterior ST‑elevation myocardial infarction (STEMI) on ECG (leads V2‑V4) with no prior medical history, what is the most appropriate definitive treatment?

Immediate Primary PCI is the Definitive Treatment

Perform immediate percutaneous coronary intervention (PCI) within 90-120 minutes of first medical contact—this is the definitive treatment for this anterior STEMI patient. 1, 2

Why Primary PCI Over Other Options

This 58-year-old man presents with classic anterior STEMI (ST-elevation in V2-V4), and the evidence unequivocally supports primary PCI as superior to all other strategies for mortality, morbidity, and quality of life outcomes. 1, 3

• Primary PCI is Class I, Level A recommendation by the European Society of Cardiology for all STEMI patients presenting within 12 hours of symptom onset 1, 2
• PCI reduces mortality, reinfarction, and stroke compared to fibrinolytic therapy when performed by experienced operators in a timely manner 1, 4, 3
• Time is critical but PCI maintains superiority: Even though time to reperfusion matters less for PCI than fibrinolysis, primary PCI remains the preferred strategy when it can be delivered within 120 minutes of STEMI diagnosis 1, 5

Why the Other Options Are Inadequate

Option A (Beta-blockers and aspirin alone): While aspirin 150-325 mg should be given immediately 2, beta-blockers without reperfusion therapy will not restore coronary flow and will result in massive myocardial necrosis and death. 1

Option B (Streptokinase): Fibrinolytic therapy is only indicated when primary PCI cannot be performed within 120 minutes of STEMI diagnosis. 1, 2 Since the question asks for "definitive treatment" and this patient is presenting to an emergency department (implying potential PCI capability), fibrinolysis is inferior and should only be used as a time-dependent alternative. 1, 3

Option C (Nitroglycerin and observation): This is completely inadequate—observation without reperfusion in an acute STEMI will result in completed infarction, heart failure, and likely death. 1

The Complete Immediate Management Algorithm

Step 1: Immediate Medications (While Preparing for PCI)

• Aspirin 150-325 mg oral or IV immediately 2, 6
• Potent P2Y12 inhibitor (prasugrel 60 mg or ticagrelor 180 mg loading dose) before or at time of PCI 1, 2
• Unfractionated heparin weight-adjusted IV bolus 2
• Morphine 4-8 mg IV for pain control, with additional 2 mg doses every 5-15 minutes as needed 1, 6

Step 2: Primary PCI Execution

• Target door-to-balloon time <90 minutes for patients presenting early (<2 hours from symptom onset) 1
• Radial access is preferred over femoral access 1
• Drug-eluting stent (DES) is standard of care for primary PCI 1
• Focus only on the infarct-related artery (culprit vessel in V2-V4 distribution, likely LAD) during the acute procedure 1

Step 3: Critical Pitfalls to Avoid

• Do NOT delay PCI to wait for troponin results—the ECG diagnosis is sufficient 1
• Do NOT perform routine thrombus aspiration—this is contraindicated (Class III) 1
• Do NOT treat non-culprit vessels during primary PCI unless the patient is in cardiogenic shock 1
• Do NOT use NSAIDs for pain relief due to prothrombotic effects 1

Post-PCI Management Essentials

• Dual antiplatelet therapy (DAPT) for 12 months: Aspirin 75-100 mg daily plus ticagrelor or prasugrel 2
• Add proton pump inhibitor if high GI bleeding risk 2
• Beta-blocker, ACE inhibitor, and high-intensity statin should be initiated per standard post-MI protocols 2
• Continuous cardiac monitoring for at least 24 hours for arrhythmia detection 1, 6

When Fibrinolysis Would Be Appropriate

The only scenario where fibrinolysis becomes the correct answer is if primary PCI cannot be performed within 120 minutes of STEMI diagnosis. 1, 2 In that specific circumstance:

• Administer fibrin-specific agent (tenecteplase preferred over streptokinase) within 10 minutes 1
• Still transfer immediately to PCI-capable center after fibrinolysis (Class I recommendation) 2
• Perform angiography within 24 hours even if fibrinolysis appears successful 1

The answer is D: Perform immediate percutaneous coronary intervention (PCI). 1, 2, 3