Clinical Practice and Cases in Emergency Medicine

Introduction: Acute ST-elevated myocardial infarction (STEMI) is a medical emergency requiring timely revascularization to preserve myocardial injury. Rural populations often experience delays in treatment leading to increased risk of complications and mortality. Emergent treatment of STEMI in a patient on long-term direct oral anticoagulation facing delays to revascularization is a complex scenario for rural physicians. 

Case Report: A 55-year-old male presented to the emergency department in rural Alaska and was diagnosed with acute inferior STEMI. The patient’s history was notable for pulmonary embolism with long-term direct oral anticoagulation. Thrombolytic therapy was not recommended and prompt revascularization via percutaneous coronary intervention (PCI) was needed; however, the nearest PCI-capable hospital was hundreds of miles away, increasing the risk of ischemic cardiomyopathy and death. The patient achieved revascularization after transport and, in the following year, experienced multiple episodes of ventricular tachycardia leading to ablation and need for implantable cardioverter-defibrillator placement.  

Conclusion: This case illustrates a complex but not uncommon scenario that rural physicians face.  In rural patients requiring acute STEMI treatment but without timely access to a PCI-capable hospital, systemic thrombolysis and immediate transfer of care is often the only option for revascularization. There is a need for clear STEMI management guidelines in anticoagulated patients who present in rural settings.