This patient with ST-elevation myocardial infarction (STEMI) should be transferred to the nearest hospital with primary percutaneous coronary intervention (PCI) capabilities for emergency PCI. Thrombolytic therapy failure, which occurs in up to 30% of patients, remains difficult to diagnose. Chest pain resolution, ST-segment elevation improvement, and reperfusion arrhythmias (most commonly an accelerated idioventricular rhythm) indicate successful thrombolysis. Although complete ST-segment elevation resolution is associated with coronary patency, it occurs in a minority of patients. Improvement in ST-segment elevation greater than 50% on an electrocardiogram (ECG) obtained 60 minutes after the administration of thrombolytic therapy is the most commonly used criterion to indicate successful reperfusion. Continued chest pain, lack of improvement in ST-segment elevation, hemodynamic instability, and the absence of reperfusion arrhythmias most likely indicate failure of thrombolytic therapy and indicate the need for rescue PCI. This patient has clear evidence of failed reperfusion or reocclusion (worsening of ST-segment elevation, persistence of symptoms) and now has signs of cardiogenic shock (low blood pressure, pulmonary edema). In patients with thrombolytic therapy failure, guidelines recommend immediate transfer for rescue PCI. In multiple trials of thrombolytic therapy failure, patients who underwent rescue PCI had a significant improvement in the rate of reinfarction when compared with those receiving conservative care, but no improvement in mortality.

The use of glycoprotein IIb/IIIa inhibitors has been tested in multiple scenarios in patients with STEMI. Based on these studies, their use has been limited owing to excessive bleeding events. In patients in whom thrombolytic therapy has failed, rescue PCI without the use of a glycoprotein IIb/IIIa inhibitor or additional thrombolytic agents is preferred.

A meta-analysis published in 2007 compared repeat thrombolytic therapy with conservative therapy in patients in whom initial thrombolytic therapy failed. This analysis showed no significant difference in mortality rates or reinfarction between the two groups, and outcomes in these groups were inferior to rescue PCI.