MBBS OSCE · Cardiology

OSCE — assessment of suspected ST-elevation myocardial infarction

An 8-minute OSCE station assessing the candidate's structured assessment, ECG interpretation, reperfusion decision and immediate drug therapy (with doses) for a patient with an anterior STEMI. Marks for the ECG-to-reperfusion time-targets and dual antiplatelet loading.

8 min stationVerification in progress
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NEET-PGINICET

Brief (to candidate)

A 55-year-old male smoker is brought to the emergency department with 1 hour of severe central crushing chest pain radiating to the left arm, with diaphoresis and breathlessness. He is anxious, BP 160/96, HR 110, SpO2 95% on air. You have 8 minutes to assess him, interpret the ECG, and outline the immediate management including reperfusion and drug therapy with doses and timing.

Candidate instructions

  1. Take a focused history and examine using an ABCDE approach; ensure a 12-lead ECG within 10 minutes.
  2. Interpret the ECG and state the diagnosis, culprit vessel and ECG criteria.
  3. State the reperfusion strategy with explicit time-targets.
  4. Outline the immediate drug therapy (antiplatelet, anticoagulant, analgesia) with doses, routes and timing.
  5. Briefly state the disposition and a key pitfall to exclude.

Examiner checklist (mark each domain / 10)

DomainKey actions expected
ABCDE / resuscitationAirway; oxygen only if SpO2 less than 90%; IV access; continuous cardiac monitoring; defibrillator at bedside
ECG ≤10 min + interpretationObtains ECG within 10 min; diagnoses anterior STEMI (V1–V4); states LAD territory; cites ST-elevation criteria (≥1 mm in 2 contiguous leads, except V2–V3 where the threshold is ≥2 mm in men 40 or over, ≥2.5 mm in men under 40 and ≥1.5 mm in women)[2]
Reperfusion strategyPrimary PCI when first-device activation is achievable within 90 min of first medical contact (120 min if transfer is needed); otherwise fibrinolysis, lytic bolus within 10 min of the STEMI diagnosis, then immediate transfer — rescue PCI if lysis fails, routine angiography 2–24 h if it succeeds; "time is muscle"[1][3]
Dual antiplatelet loadingAspirin 150–300 mg chewed + ticagrelor 180 mg (or clopidogrel 300–600 mg); DAPT 12 months[3]
Anticoagulation + analgesiaParenteral anticoagulant matched to the pathway — unfractionated heparin to support primary PCI, or enoxaparin (30 mg IV bolus then 1 mg/kg SC 12-hourly if under 75 years) alongside fibrinolysis; titrated IV opioid with an antiemetic[3]
Diagnosis & definitionStates STEMI; cites Universal Definition (troponin rise/fall ≥99th percentile URL + ischaemia)[2]
Pitfall & safety-netExcludes aortic dissection before anticoagulating (unequal pulses/BP); mentions VF risk and secondary prevention

Model key actions

  • ECG within 10 minutes and correctly read as anterior STEMI; localises to LAD.[1]
  • Reperfusion: primary PCI when deliverable within 120 min of the STEMI diagnosis; otherwise fibrinolysis (e.g. tenecteplase) with the bolus inside 10 min of that diagnosis; pharmaco-invasive transfer.[1]
  • Immediate drugs: aspirin 150–300 mg chewed + ticagrelor 180 mg loading + parenteral anticoagulant + titrated IV opioid.[3]
  • Secondary prevention started in hospital: high-intensity statin, beta-blocker, ACE-inhibitor (especially LV dysfunction/anterior MI); cardiac rehabilitation.
  • Recognises and states management of VF (immediate defibrillation) and the mechanical complications (new murmur — ventricular septal rupture typically within 24 h, papillary muscle rupture peaking at days 2–7, free-wall rupture from 24–48 h to the first week).[4]

Common errors

  • Delaying or not obtaining the ECG within 10 minutes; misreading the ECG.
  • Not stating the explicit time-targets for PCI versus fibrinolysis.
  • Giving oxygen routinely to a non-hypoxic patient, or nitrates/diuretics if RV infarct is present.
  • Omitting the loading P2Y12 inhibitor or parenteral anticoagulation.
  • Failing to exclude aortic dissection before antiplatelet/anticoagulant therapy.[1]
References4Show
  1. [1]Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 2018.PMID 28886621
  2. [2]Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). Journal of the American College of Cardiology, 2018.PMID 30153967
  3. [3]Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2025.PMID 40014670
  4. [4]Meza-González YA, Manzur-Barbur MC, Ochoa-Díaz AF, et al. Untangling Mechanical Complications of Acute Myocardial Infarction. JACC Case Rep, 2025.PMID 40185591
OSCE — assessment of suspected ST-elevation myocardial infarction · MBBS OSCE · NeetVellum