Inferior STEMI in a polyclinic with no thrombolysis and a hypotensive patient
A 58-year-old Bangladeshi accountant walks into your polyclinic at 14:20, 90 minutes after the onset of central crushing chest pain that began while he was climbing stairs. He is grey, clammy and clearly frightened. Blood pressure is 88/58 mmHg, pulse 112 regular, respiratory rate 24, SpO2 94% on room air, temperature 36.8°C. The ECG shows 2 mm ST elevation in leads II, III and aVF with reciprocal depression in I and aVL. He has type 2 diabetes and smokes 20 cigarettes a day. The clinic has oxygen, aspirin, clopidogrel, sublingual nitrates, IV fluids, a monitor and a defibrillator, but no troponin assay and no thrombolytic. The nearest PCI centre is 25 minutes away by ambulance and the ambulance service estimates 15 to 20 minutes to arrive. He wants to go home first to take his own tablets and to call his brother, and says he does not want to go to hospital because he is worried about cost and about his work visa.
1. What do you do in the first ten minutes in the clinic, and what do you deliberately avoid?
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Treat this as a time-critical STEMI with cardiogenic shock risk.
Do: call the ambulance immediately rather than after stabilising, because the clock is running and the transfer team is the definitive care; put him on the monitor and attach the defibrillator pads; secure IV access; give aspirin 300 mg chewed; give a P2Y12 inhibitor (clopidogrel 300 to 600 mg, or ticagrelor 180 mg if stocked) unless there is a contraindication; give oxygen only if SpO2 falls below 90%, since routine oxygen in a normoxic patient is harmful; treat nausea with an antiemetic.
Avoid: sublingual or IV nitrates, which would drop his systolic pressure further and are contraindicated at 88 mmHg; intramuscular injections, which complicate later anticoagulation and fibrinolysis; NSAIDs; and routine high-flow oxygen.
The hypotension with an inferior infarct should make you think of right ventricular involvement: do right-sided leads (V4R). If V4R shows ST elevation, give a cautious fluid challenge of 250 to 500 mL and reassess, because the RV is preload-dependent, and keep nitrates and opioids away from him. Document serial observations every five minutes and repeat the ECG if the rhythm or pain changes.
2. Explain the transport and destination decision, including when thrombolysis would have been the right choice.
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The default is primary PCI if it can be delivered within 120 minutes of first medical contact. Here the PCI centre is 25 minutes away, so even allowing 20 minutes for the ambulance he is well inside the window; primary PCI is clearly the right strategy and the ECG should be transmitted or described to the receiving team before departure.
Pre-alert matters as much as transport. State the diagnosis, the blood pressure, the time of symptom onset and the anticipated arrival time so the catheter laboratory is activated and the patient bypasses the emergency department.
Thrombolysis becomes the preferred option when primary PCI cannot be delivered within 120 minutes, for example if the catheter laboratory is down, the ambulance is delayed beyond an hour, or the patient presents in a remote area and the transfer time exceeds two hours. In that situation, with ST elevation and symptom onset under 12 hours, a fibrin-specific agent would be given after checking for contraindications, with a plan for rescue PCI. Here, with no thrombolytic on site and a 25-minute transfer, rushing the transfer is safer than improvising fibrinolysis.
Note also that hypotension is not a reason to delay reperfusion; it is a reason to move faster and to involve the receiving team early.
3. He insists on going home to fetch his tablets and call his brother. How do you handle this?
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First check whether the refusal is capacitous. Capacity requires that he understands the information, retains it, weighs it and communicates a choice. He is in pain, frightened, hypoxic enough to matter and has just received opioids or may do so; reassess after treating pain and after a clear explanation.
Explain in his own language, with a interpreter if needed, that this is a blocked artery, that the risk of death or major arrhythmia in the next hour is substantial, that the hospital will treat him as an emergency and that he should not preoccupy himself with cost at this moment; in Kuwait, emergency care in the public system is not the barrier he fears, and the social worker can address the rest. Offer to call his brother yourself, from the clinic phone, and to have someone bring his tablets to the hospital later.
If, after that, he still has capacity and still refuses, document the discussion, the risks explained, the alternatives offered and his reasons; give aspirin and clopidogrel to take, arrange immediate ambulance or accompanied transport anyway, inform the receiving hospital and arrange a follow-up call within the hour. If he lacks capacity, act in his best interests and transfer him; involve his brother as next of kin but do not let the absence of consent delay transfer.