A 53-year-old man presents to Casualty with severe chest pain. He has a history of angina. ECG shows ST elevation of 4 mm in leads V1 and V4 Thrombolysis has been done but pain and ECG findings are persisting 90 minutes after start of thrombolysis. What is the best management of this patient?

**Core Concept**
The underlying principle being tested is the management of acute **ST-Elevation Myocardial Infarction (STEMI)**, particularly in cases where thrombolysis is ineffective. This involves understanding the **reperfusion strategies** in acute myocardial infarction.

**Why the Correct Answer is Right**
In cases of STEMI where thrombolysis is unsuccessful, as indicated by persistent chest pain and ST elevation on ECG 90 minutes after initiation of thrombolysis, the best management involves considering alternative reperfusion strategies. This is because timely restoration of blood flow to the affected myocardium is crucial to salvage ischemic tissue and improve outcomes.

**Why Each Wrong Option is Incorrect**
**Option A:** Incorrect because, although it might be a consideration in some contexts, it doesn't directly address the need for immediate reperfusion in the setting of failed thrombolysis.
**Option B:** Incorrect as it does not specify a reperfusion strategy.
**Option C:** Incorrect because, without more context, it's not the best next step after failed thrombolysis.
**Option D:** Incorrect as it's not the best course of action when thrombolysis fails.

**Clinical Pearl / High-Yield Fact**
In STEMI management, if thrombolysis is unsuccessful, **primary percutaneous coronary intervention (PCI)** should be considered as soon as possible to achieve timely reperfusion, as it offers better outcomes compared to repeat thrombolysis or conservative management.

**Correct Answer:** D. Rescue PCI.

✓ Correct Answer: A. Rescue PCI