A 62-year-old man presents with sudden-onset chest pain, diaphoresis, and hypotension. ST-segment elevation in inferior leads II, III, and aVF is noted. What is the most appropriate next step in management?

• A. Begin diuretics and observe for further deterioration.
• B. Activate emergent reperfusion therapy with PCI if available.
• C. Administer beta-blockers and IV nitroglycerin in the ED.
• D. Observe and perform stress testing later.

Answer: (B)

In acute ST-elevation myocardial infarction, the priority is rapid reperfusion to salvage myocardium and improve survival. When the infarct shows inferior involvement, often from right coronary artery occlusion, the patient may be hypotensive, which makes agents that lower preload (like nitrates) risky, so the focus remains on restoring blood flow quickly.

The most appropriate next step is emergent reperfusion therapy with PCI if it is available. Prompt PCI (door-to-balloon time within guidelines) restores coronary perfusion and reduces mortality and ventricular complications. If PCI cannot be performed promptly, systemic thrombolysis is the alternative, but PCI is preferred whenever feasible.

Delaying for diuretics and observation does not address the blocked artery and can worsen outcomes. Giving beta-blockers and IV nitroglycerin in the setting of hypotension or suspected right ventricular infarction can worsen blood pressure and is not ideal initially. Observing and scheduling stress testing later is contraindicated in the acute STEMI.