Tenecteplase Failure in STEMI: A Case Highlighting the Need for Expedited Transfer for Rescue PCI

: Background ST-elevation myocardial infarction (STEMI) requires rapid reperfusion to reduce morbidity and mortality. While percutaneous coronary intervention (PCI) is the preferred strategy, fibrinolytic therapy remains an important alternative in settings where timely PCI is not available. However, even with apparent reperfusion, patients remain at risk for failed therapy and re-occlusion, necessitating prompt transfer for definitive management. Case Presentation An elderly male with a history of hypertension, diabetes mellitus, and hyperlipidemia presented with acute-onset chest pain and diaphoresis. Initial electrocardiogram demonstrated findings concerning for STEMI, and point-of-care ultrasound revealed regional wall motion abnormalities. Given limited access to timely PCI, the patient was treated with tenecteplase (TNK). Subsequent electrocardiographic changes suggested reperfusion; however, during transfer to a PCI-capable facility, the patient developed worsening chest pain and worsening EKG findings. On arrival, emergent coronary angiography was performed, confirming the need for definitive revascularization. Conclusion This case highlights the limitations of fibrinolytic therapy and the importance of rapid transfer for PCI, even in the setting of apparent initial reperfusion. Ongoing vigilance is required, as clinical deterioration may indicate failed reperfusion or re-occlusion requiring emergent intervention.