In a 52‑year‑old Indian woman with type‑2 diabetes mellitus presenting with crushing chest pain, diaphoresis, and minor ST‑segment elevation in contiguous leads, and no on‑site percutaneous coronary intervention (PCI) facility, what is the appropriate reperfusion and transfer strategy?

Thrombolysis and Transfer Strategy for STEMI Without On-Site PCI

Your plan to thrombolyse and immediately transfer to a higher PCI-capable centre is the correct strategy for this patient. 1

Immediate Thrombolytic Administration

Initiate fibrinolytic therapy immediately—within 10 minutes of STEMI diagnosis—as you cannot achieve primary PCI within 120 minutes of first medical contact. 1

Choice of Fibrinolytic Agent

• Use a fibrin-specific agent: tenecteplase (preferred for single bolus), alteplase, or reteplase (Class I, Level B recommendation). 1
• Tenecteplase is weight-based: 30 mg if <60 kg, 35 mg if 60-69 kg, 40 mg if 70-79 kg, 45 mg if 80-89 kg, 50 mg if ≥90 kg, given as single IV bolus over 5 seconds. 2
• If cost is a major constraint and fibrin-specific agents are unavailable, streptokinase 1.5 million units IV over 30-60 minutes is acceptable, though inferior. 3, 4

Mandatory Adjunctive Antiplatelet Therapy

• Aspirin 150-325 mg oral (chewable) or IV immediately (Class I, Level B). 1, 3
• Clopidogrel 300 mg loading dose if age <75 years; 75 mg if age ≥75 years (Class I, Level A). 1, 3
• Continue aspirin 75-100 mg daily indefinitely. 1
• Continue clopidogrel 75 mg daily for at least 14 days, ideally 12 months. 1

Mandatory Adjunctive Anticoagulation

• Enoxaparin is preferred over unfractionated heparin (Class I, Level A): 30 mg IV bolus, then 1 mg/kg subcutaneous every 12 hours (reduce to 0.75 mg/kg if age ≥75 years; 1 mg/kg once daily if creatinine clearance <30 mL/min). 1
• Alternative: Unfractionated heparin 60 units/kg IV bolus (maximum 4000 units), then 12 units/kg/hour infusion (maximum 1000 units/hour), adjusted to aPTT 1.5-2.0 times control (Class I, Level B). 1
• Continue anticoagulation until revascularization or for duration of hospital stay up to 8 days. 1

Immediate Transfer Protocol

Transfer to the PCI-capable centre must begin immediately after fibrinolytic administration—do not wait to assess reperfusion success (Class I, Level A). 1

Critical Transfer Considerations

• Arrange transfer during or immediately after thrombolytic infusion, not after waiting for clinical response. 1
• Ensure continuous cardiac monitoring with defibrillation capability during transport. 3
• Communicate clearly with receiving facility about fibrinolytic agent used, time of administration, and patient's diabetes status. 1
• Patient should bypass emergency department at receiving hospital and go directly to catheterization laboratory if rescue PCI needed. 1

Assessment of Fibrinolysis Success During Transfer

Monitor ST-segment resolution at 60-90 minutes post-fibrinolysis. 1

Rescue PCI Indications (Immediate Catheterization on Arrival)

• <50% ST-segment resolution at 60-90 minutes = failed fibrinolysis (Class I, Level A). 1
• Hemodynamic instability or cardiogenic shock (Class I, Level A). 1, 3
• Electrical instability (sustained ventricular arrhythmias). 1
• Worsening or recurrent chest pain with ST-segment re-elevation. 1

Routine Early PCI After Successful Fibrinolysis

If fibrinolysis appears successful (>50% ST-segment resolution, chest pain relief, reperfusion arrhythmias), perform angiography and PCI of the infarct-related artery 2-24 hours after fibrinolytic administration (Class I, Level A). 1

• This pharmacoinvasive strategy reduces reinfarction and recurrent ischemia compared to waiting. 1, 5
• Optimal timing is 2-24 hours post-lysis; very early (<2 hours) is safe but not superior. 1

Antiplatelet Transition at PCI-Capable Centre

After successful PCI, switch from clopidogrel to a potent P2Y12 inhibitor 48 hours post-fibrinolysis: 1

• Ticagrelor 90 mg twice daily (preferred) or prasugrel 10 mg daily (if age <75 years, weight ≥60 kg, no prior stroke). 1
• Continue dual antiplatelet therapy (aspirin + ticagrelor/prasugrel) for 12 months unless excessive bleeding risk. 1, 3

Critical Pitfalls to Avoid

• Do NOT delay fibrinolysis to arrange transfer—give the lytic first, then transfer immediately. 1
• Do NOT wait to assess reperfusion before transferring—all fibrinolysis patients require transfer regardless of apparent success. 1
• Do NOT re-administer fibrinolysis if the first dose fails—rescue PCI is the only option for failed lysis. 1
• Do NOT use fondaparinux as anticoagulant—it is contraindicated in this setting (Class III, Level B). 1
• Do NOT perform routine PCI of an occluded artery >48 hours after symptom onset if patient is asymptomatic and stable (Class III, Level A). 1, 3

Special Considerations for This Patient

Given her diabetes mellitus, she is at higher risk for:

• Silent ischemia—monitor closely even if chest pain resolves. 4
• Bleeding complications—use weight-based dosing of anticoagulants carefully. 1, 2
• Worse outcomes if reperfusion is delayed—making immediate fibrinolysis and transfer even more critical. 1, 4