A 55-Year-Old Construction Worker Is Brought to the Emergency Department

A 55-year-old construction worker is brought to the emergency department 2 hours after awakening with severe left chest discomfort.  He appears diaphoretic and uncomfortable.  He has no other medical problems and has not seen a physician in 5 years.
His blood pressure is 152/88 mm Hg and pulse is 92/min.  Examination shows clear lung fields, normal first and second heart sounds, and the presence of a fourth heart sound.  His initial EKG shows sinus rhythm with a 3-mm ST-segment elevation in leads V1-V4.
The hospital does not have a cardiac catheterization laboratory and the closest hospital with angioplasty capabilities is 2 hours away.  The patient is given a single bolus dose of tenecteplase over 10 seconds.  His chest discomfort subsides completely, and a repeat EKG 30 minutes after injection shows near-complete resolution of the ST-segment elevation.
Which of the following is the best next step in managing this patient?

A) Admit to telemetry floor
B) Admit to intensive care unit
C) Transfer to angioplasty-capable hospital immediately
D) Transfer to angioplasty-capable hospital after 24 hours of observation
E) Transfer to angioplasty-capable hospital only if patient has recurrent chest pain

Correct Answer:

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