What is the appropriate management of a patient presenting with ST‑elevation myocardial infarction who also has a manubrial mass?

Management of STEMI with Concurrent Manubrial Mass

Proceed immediately with standard STEMI reperfusion therapy—either primary PCI or fibrinolysis—without delay for evaluation of the manubrial mass, as the acute myocardial infarction takes absolute priority over investigation of an incidental finding. 1

Immediate STEMI Management Takes Precedence

The presence of a manubrial mass does not alter the fundamental approach to STEMI, which remains a time-critical emergency where every minute of delay increases mortality and morbidity. 2

Primary Reperfusion Strategy

• Obtain a 12-lead ECG within 10 minutes of arrival and administer aspirin 75–100 mg (oral or IV) immediately unless contraindicated. 1, 3

• Pursue primary PCI as the preferred reperfusion method if it can be performed without delay (ideally within 90–120 minutes of first medical contact). 1, 3

• Transfer the patient directly to the catheterization laboratory, bypassing the emergency department. 1, 3

• Administer a potent P2Y12 inhibitor (prasugrel or ticagrelor preferred; clopidogrel if unavailable) before or at the time of PCI and continue for 12 months. 1, 3

• Use unfractionated heparin or enoxaparin for anticoagulation during primary PCI; fondaparinux is contraindicated. 1, 3

If Primary PCI Cannot Be Performed Promptly

• Administer fibrinolytic therapy within 12 hours of symptom onset if primary PCI cannot be performed within 120 minutes of STEMI diagnosis. 1

• Select a fibrin-specific agent (tenecteplase, alteplase, or reteplase). 1

• Add aspirin and clopidogrel to the fibrinolytic regimen. 1

• Use enoxaparin (IV bolus followed by subcutaneous dosing) for anticoagulation; weight-adjusted UFH is an alternative. 1

• Transfer immediately to a PCI-capable center after fibrinolysis. 1

Considerations Specific to the Manubrial Mass

Bleeding Risk Assessment

The manubrial mass warrants consideration only insofar as it might represent a bleeding-prone lesion (e.g., vascular malformation, highly vascularized tumor, or metastatic disease with erosion potential). However, this theoretical concern does not justify delaying reperfusion therapy. 1, 2

• If the mass is known to be a benign bone lesion, lipoma, or other low-risk entity from prior imaging, proceed with standard antithrombotic therapy without modification. 4, 1

• If the mass is unknown or potentially high-risk for bleeding (e.g., suspected hemangioma or metastatic lesion), still proceed with reperfusion but consider radial access for PCI to minimize access-site complications. 1

• Routine radial access is already the standard of care during primary PCI and offers lower bleeding risk regardless of the manubrial mass. 1

Contraindications to Fibrinolysis

• Absolute contraindications to fibrinolysis include prior intracranial hemorrhage, known structural cerebrovascular lesion, known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding or bleeding diathesis, and significant closed-head or facial trauma within 3 months. 4

• A manubrial mass alone is not an absolute contraindication to fibrinolysis unless there is active bleeding from the mass or documented high risk of hemorrhage (e.g., known vascular tumor with prior bleeding episodes). 4, 1

• If fibrinolysis is contraindicated due to bleeding risk from the mass, primary PCI becomes the only reperfusion option and must be pursued emergently. 1

Post-Reperfusion Evaluation of the Manubrial Mass

• Defer imaging and evaluation of the manubrial mass until after successful reperfusion and hemodynamic stabilization (typically after 24 hours of monitoring). 1, 3

• Routine echocardiography is indicated during hospitalization to assess left ventricular function and complications; this may incidentally visualize anterior mediastinal structures but is not intended for mass evaluation. 1

• If the mass requires further characterization, CT or MRI can be performed after the acute STEMI phase, typically before discharge or in early outpatient follow-up. 1

Common Pitfalls to Avoid

• Do not postpone reperfusion therapy to obtain CT imaging of the manubrial mass; the STEMI takes absolute priority. 1, 3

• Do not withhold aspirin or P2Y12 inhibitors based solely on the presence of an uncharacterized mass without documented active bleeding. 1

• Do not delay transfer to a PCI-capable center for additional diagnostic workup of the mass. 1

• Do not use fondaparinux as anticoagulation for primary PCI, regardless of bleeding concerns. 1, 3

Adjunctive Therapies

• Initiate high-intensity statin therapy as early as possible unless contraindicated. 4, 3

• Start an ACE inhibitor within 24 hours in patients with heart failure, left ventricular ejection fraction <40%, diabetes, or anterior infarction. 3

• Begin oral beta-blocker therapy in patients with heart failure and/or LVEF <40% unless contraindicated; avoid IV beta-blockers in hypotension, acute heart failure, high-grade AV block, or severe bradycardia. 3

• Continue dual antiplatelet therapy (aspirin plus ticagrelor or prasugrel) for 12 months unless bleeding risk is excessive. 1, 3