**Question:** A 70-year-old man with a history of coronary artery disease presents to the emergency department with 2 hours of substernal chest pressure, diaphoresis, and nausea. He reports difficulty "catching his breath." An electrocardiogram shows septal T-wave inversion. The patient is given 325 mg aspirin and sublingual nitroglycerin while awaiting the results of his blood work. His troponin I is 0.65 ng/mL (normal <0.04 ng/mL). The physician in the emergency department starts the patient on low-molecular-weight heparin. His pain is 3/10. Blood pressure is currently 154/78 and heart rate is 72. You are asked to assume care of this patient. What is the best next step in management? A. Continue low-molecular-weight heparin B. Administer thrombolytic therapy C. Discontinue low-molecular-weight heparin and start oral anticoagulant therapy D. Observe and continue nitroglycerin **Correct Answer:** B. Administer thrombolytic therapy **Core Concept:** The patient presents with typical angina symptoms (substernal chest pressure, diaphoresis, and difficulty catching his breath) and has a history of coronary artery disease, elevated cardiac biomarkers (troponin I), and ST-segment elevation on electrocardiogram (ECG) consistent with ST-elevation myocardial infarction (STEMI). **Why the Correct Answer is Right:** Given the clinical context and diagnostic test results, the patient is experiencing an acute myocardial infarction (heart attack) due to a blockage in a coronary artery. The correct management involves reperfusion therapy, which aims to restore blood flow to the ischemic (starving) heart muscle. The most effective reperfusion therapy for ST-elevation myocardial infarction is thrombolytic therapy (clot-busting medication). This is because it directly breaks down the blood clot blocking the coronary artery and restores blood flow to the ischemic myocardium. **Why Other Options are Incorrect:** A. Continuing low-molecular-weight heparin (LMWH) does not directly address the ischemic heart muscle and is primarily used for anticoagulation. It is less effective in restoring blood flow compared to thrombolytic therapy. C. Discontinuing LMWH and initiating oral anticoagulant therapy is not the best choice because it does not address the current acute event, which is a STEMI. Oral anticoagulant therapy is intended for chronic management of thromboembolic events, not acute treatment. D. Continuing nitroglycerin does not directly address the ischemic heart muscle and is primarily used to relieve angina symptoms. Nitroglycerin is a vasodilator, causing blood vessels to dilate, which may worsen the patient's condition due to worsening the flow of blood to the ischemic myocardium. **Clinical Pearls:** 1. In acute myocardial infarction, reperfusion therapy is essential to restore blood flow to the ischemic myocardium