Volume 77, Number 9

Combined reperfusion strategies in ST-segment elevation MI:
Rationale and current role

1. A 52-year-old man presents within 2 hours of the start of chest pain to a hospital with no facilities for percutaneous coronary intervention (PCI). Electrocardiography shows anterior ST-segment elevation. His blood pressure is 109/67 mm Hg, and his heart rate is 105 bpm. He has no known contraindication to thrombolysis. The closest PCI hospital is 60 miles away, and no community transfer system is in place. Which is the best reperfusion strategy for this patient?

1. Do not give thrombolysis; transfer for primary PCI
2. Immediate thrombolysis and immediate transfer to a PCI-capable hospital for consideration of routine early PCI within 24 hours of presentation, or for rescue PCI if thrombolysis fails; give aspirin, heparin, and clopidogrel (Plavix) 300 mg before transfer
3. Immediate thrombolysis; transfer to a PCI center only if thrombolysis has failed at 90 minutes after start of therapy; if transferring, give aspirin, heparin, and clopidogrel (Plavix) 300 mg before transfer
4. Give aspirin, a beta blocker, heparin, and clopidogrel (Plavix) 300 mg and transfer for primary PCI