Question 1 of 182

A 58-year-old man presents to a rural emergency department 90 minutes after the onset of crushing substernal chest pain radiating to his left arm, associated with diaphoresis and nausea. Vital signs: BP 138/84 mmHg, HR 92/min, RR 18/min, SpO2 97% on room air. ECG shows 3 mm of ST-segment elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. The nearest percutaneous coronary intervention (PCI)-capable facility is a 2.5-hour drive away, and no helicopter transport is available. He has no contraindications to thrombolysis. Which of the following is the most appropriate next step in management?

• A.Administer fibrinolytic therapy now and arrange transfer to a PCI-capable center
• B.Transfer for primary PCI regardless of anticipated delay
• C.Give aspirin and admit for serial troponins before deciding on reperfusion
• D.Obtain a right-sided ECG and withhold reperfusion until results return
• E.Start a nitroglycerin drip and reassess the ECG in 60 minutes