Slide 1: 43-year-old male with cardiac arrest at work. S/p quick return of spontaneous circulation in the field. What abnormality do you see? EKG for patient shown.

Slide 2: STEMI alert! EKG showing reciprocal ST depressions in inferior leads. EKG showing ST elevation in V2-6 (also I and aVL). Anterolateral distribution in territory of LAD! Patient was taken to a center without catheterization capability. What do you do now?

Slide 3: Fibrinolytic therapy! If unable to perform PCI within 2 hours of first medical contact, fibrinolytic therapy is indicated to establish reperfusion. Administer within 30 minutes of arrival to hospital. Best to use within 12 hours (and in certain cases effective up to 24 hours) of symptom onset.

Slide 4: Fibrinolytics running…now what? Anti-platelets? Yes! Aspirin 325 mg as usual plus loading does of P2Y12 inhibitor for patients less than 75 years old. Anticoagulation? Yes! Un-fractionated heparin or enoxaparin. There is some evidence for better outcomes with enoxaparin, but often UFH is used in case emergent cath is required. Used as adjunctive therapy to prevent re-occlusion of lysed thrombus. How do we know it’s working? Chest pain resolution and reduction in ST elevations by greater than 50 percent at 90 minutes. The degree of ST-segment resolution (complete, partial, none) is the most powerful clinical predictor of 35-day and 10-year mortality.

Slide 5: Patient is hemodynamically stable with repeat EKG. What is the next step? Patient EKG shown.

Slide 6: Drip and ship. i.e, transfer to PCI-capable center regardless of the success of fibrinolytic! Two EKGs showing resolution of STEs. Cath greater than 3 hours but less than 24 hours from time of fibrinolytic. Emergent cath indicated if recurrent STEs, arrhythmia (VT, VF), heart failure or cardiogenic shock.