In a patient with STEMI unable to undergo PCI within 120 minutes, which treatment is the best pharmacological option?

In a patient with STEMI who is unable to undergo percutaneous coronary intervention (PCI) within 120 minutes, the optimal pharmacological treatment is weight-based tenecteplase with heparin. This approach is supported by evidence indicating that thrombolytic therapy is effective in restoring blood flow when immediate PCI is not feasible.

Tenecteplase is a fibrinolytic agent that has a shorter infusion time compared to alteplase and has a favorable safety profile. The use of heparin in conjunction with tenecteplase helps to prevent reocclusion of the coronary artery and improves overall outcomes by enhancing clot resolution. This combination is particularly advantageous in the context of STEMI because it addresses the acute thrombotic event quickly, improving the chances of salvaging heart muscle and reducing mortality.

While alteplase is another thrombolytic agent, it often requires a longer infusion time and is less commonly preferred over tenecteplase due to these practical considerations in emergency settings. Ischemia-guided medical therapy does not provide the rapid intervention necessary to restore coronary perfusion in the acute setting of STEMI. Immediate PCI at a distant facility may not be viable given the time constraint and the urgency of restoring blood flow,