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55F presents with acute onset dyspnea and pleuritic chest pain. CT-PA confirms bilateral PE with right heart strain. BP 100/68, HR 118, SpO2 88% on room air. Echo shows RV dilation and McConnell sign. Troponin mildly elevated. PESI score is 95 (Class III). She is hemodynamically borderline. Should I use PESI or sPESI to guide thrombolysis decision? What's the threshold for systemic thrombolysis vs catheter-directed therapy?

65M post-anterior STEMI with primary PCI done. Now in ICU with BP 82/50, HR 118, lactate 4.5, cold extremities, urine output 10ml/hr. Echo shows EF 20%, no mechanical complication. On low-dose dopamine currently. Should we switch to norepinephrine? Add dobutamine? Or go straight to IABP or Impella? What does the CULPRIT-SHOCK trial teach us about culprit-only vs multivessel PCI in this scenario?

58M presents with 45-minute chest pain, anterior ST elevation in V1–V4. We are a non-PCI capable center. Nearest cath lab is 2 hours away. ACC/AHA guidelines recommend primary PCI if door-to-balloon time is under 120 minutes from first medical contact. In our scenario, fibrinolysis seems indicated. What are the key contraindications to check before administering alteplase, and should we transfer post-lysis regardless of clinical reperfusion signs?

35F, post-emotional stress, anterior ST elevation V1-V4, troponin 3.2, echo shows apical ballooning. Cardiology pushing for immediate cath. What do current ACC/AHA criteria say?