This patient should receive a thrombolytic agent such as tenecteplase and be transferred to a center capable of performing percutaneous coronary intervention (PCI). He has electrocardiographic changes consistent with an acute inferior ST-elevation myocardial infarction (STEMI). Patients with a STEMI presenting within 12 hours of symptom onset should receive reperfusion therapy with either primary PCI or thrombolysis, with PCI being the preferred intervention owing to increased efficacy. When transfer times for primary PCI exceed 120 minutes from presentation, administration of thrombolytic therapy is recommended, such as in this patient presenting to a facility without PCI capability and an inability to transport him for treatment within that time frame.

This patient has no absolute contraindications to thrombolytic therapy, which include previous intracerebral hemorrhage, a known cerebrovascular lesion (such as an arteriovenous malformation), suspected aortic dissection, active bleeding or bleeding diathesis (excluding menses), significant closed head or facial trauma within 3 months, and ischemic stroke within the past 3 months. A relative contraindication for thrombolysis is severe hypertension (defined as a systolic blood pressure >180 mm Hg); however, this patient's systolic blood pressure does not meet this threshold. Even when thrombolytic therapy is administered, treatment guidelines recommend that patients be transferred to a PCI-capable facility because of the potential for thrombolytic failure. Optimal management of patients with STEMI relies heavily upon physician recognition and rapid initiation of reperfusion therapy, with either thrombolytic therapy or PCI. Patients with an acute coronary syndrome and an electrocardiogram compatible with STEMI should be treated with reperfusion therapy without biomarker confirmation, as early biomarker results may be normal in patients with STEMI. Therefore, waiting for the results of cardiac biomarker levels would delay appropriate treatment.

The use of a glycoprotein IIb/IIIa inhibitor, such as abciximab, has not been shown to improve outcomes of patients with STEMI prior to the primary PCI procedure and should be reserved for administration in the catheterization laboratory during primary PCI.

Transfer for primary PCI is a reasonable alternative to thrombolytic therapy in the setting of absolute contraindications to thrombolytic therapy or high-risk clinical features and if an acceptable time to transfer the patient to a PCI-capable hospital can be achieved (first medical contact–to–device time of 120 minutes or less). In studies of patients transferred from a non-PCI facility for primary PCI, more than half of patients with STEMI did not undergo perfusion in 120 minutes or less. In this case, transfer time would be prolonged (>120 minutes); therefore, thrombolytic therapy is the best reperfusion strategy.