A 62-year-old man presents with abrupt onset crushing chest pain radiating to the left arm, diaphoresis, and shortness of breath. ECG shows ST elevations in leads II, III, and aVF. What is the most appropriate initial management?

• A. Activate emergent PCI with aspirin and heparin; arrange urgent coronary angiography.
• B. Start thrombolytic therapy (rtPA) if PCI not available
• C. Begin nitrates and oxygen only
• D. Observe and provide analgesia

Answer: (A)

When a patient has a ST-elevation MI, the priority is to restore blood flow to the blocked coronary artery as rapidly as possible. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy when it can be performed promptly because it restores perfusion more reliably and reduces mortality compared with fibrinolysis. In this scenario, the best initial management is to activate the catheterization lab for emergent PCI and give aspirin to inhibit platelet aggregation plus heparin to prevent further clot propagation during the procedure. Arranging urgent coronary angiography follows so the interventional team can identify the culprit lesion and perform PCI immediately if feasible.

Thrombolytic therapy is an option only when PCI cannot be performed promptly. Nitrates and oxygen alone do not treat the underlying occlusion and won’t suffice as definitive therapy for a STEMI. Observing and analgesia without reperfusion would allow ongoing myocardial damage.