A rural STEMI case raises questions that current evidence can’t fully answer
Over the holiday break, RRECN member Lauren encountered a STEMI case that illustrates what happens when guidelines meet geography—and why her scoping review on pharmaco-invasive therapy is so necessary.
The patient, a man in his 50s we’ll call Nick, presented to a rural emergency department after driving more than an hour from home, leaving almost immediately after the onset of chest pain. His ECG showed an inferior ST-elevation myocardial infarction (STEMI) with atypical features, raising concern for unusual coronary anatomy and possible right ventricular infarction.
Because there was no nearby cardiac catheter lab for an angioplasty, Nick received fibrinolysis to dissolve the clot in his artery. What followed highlights one of the central challenges in rural STEMI care: how to assess whether the clot has dissolved (reperfusion) and how to act when that assessment is equivocal.
Early post-lysis ECGs showed little ST-segment resolution, although Nick reported symptomatic improvement. A little later, transient arrhythmias, which can occur as blood flow returns, raised hope of reperfusion; however, ST elevation persisted, and residual chest discomfort remained.
Recognising failed thrombolysis — and when to transfer
While guidelines support a pharmaco-invasive (fibrinolysis then transfer to a cath lab) strategy), the practical reality is that “hot transfer” varies widely between health regions. In some settings, all STEMI patients are transferred as a priority regardless of reperfusion status, while in others clinicians are expected to reassess reperfusion and use this to guide the timing of transfer. These decisions are constrained by distance, terrain, and weather, as well as by the limited evidence available to guide escalation when reperfusion is uncertain. Anticipated studies such as the TROFAMI study, which aims to identify biomarkers predictive of failed prehospital thrombolysis, may help identify patients who need earlier escalation and stronger advocacy for transfer.
Despite early engagement with cardiology and retrieval services, concern remained that Nick was at high risk of failed fibrinolysis.
At the 60-minute mark, Nick still had no ECG evidence of reperfusion, and a full retrieval team was dispatched. In the context of significant clinical improvement, and given the lack of evidence supporting the safety of further immediate intervention — such as repeat fibrinolysis — the team did not escalate treatment further at that point.
By the time the transfer occurred, Nick’s ST-elevation had resolved. Angiography the following day revealed triple-vessel disease, and he ultimately underwent percutaneous coronary intervention. He did not choose surgery as the recovery time and prolonged separation from home associated with the operation were not acceptable to him.
Reflecting on the case raised questions that extend well beyond a single patient. Management of STEMI in geographically isolated rural settings is a recurring challenge. What constitutes failed fibrinolysis, and how reliably can it be identified outside tertiary centres? Which patients are under-represented in the trials that inform current definitions and thresholds? Can failed reperfusion be predicted early enough to meaningfully change rural management? And critically, what should clinicians do when reperfusion appears incomplete, but access to the catheter laboratory is delayed by geography rather than indecision?
These uncertainties lie at the heart of the STEMI scoping review — not whether rural clinicians can deliver guideline-based care, but how existing research has approached these questions, how geography, retrieval systems, and limited resources are represented in that literature, and where important gaps remain.
TROFAMI study — Predictors of Failed Thrombolysis in Acute Myocardial Infarction.
Study overview available at: https://ctv.veeva.com/study/predictors-of-failed-thrombolysis-in-acute-myocardial-infarction
First published in the RRECN Newsletter (February 2026).
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