Delayed Revascularization in Rural Acute STEMI Patient on Direct Oral Anticoagulation: A Case Report

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.