Clinical Commander

All dossiers
cardio.stemi.anterior.v1

Anterior wall STEMI (LAD culprit)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.stemi.core.v1 — narrowed to anterior wall (LAD culprit). Inherits reperfusion + antiplatelet + statin + BB regimen from parent via routing; specializes complication profile (LV thrombus, anterior aneurysm, septal VSR) and post-MI surveillance (5-7d thrombus screen + 40-90d ICD eligibility per MADIT-II + WCD bridge per VEST). Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (anterior-specific differences documented inline in this dossier). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as the variant-template proof.

Entry points (3)

  • imaging
    ST elevation V1–V6 + reciprocal ST↓ inferior leads (anterior STEMI)
    ecg_anterior_st_elevation
  • symptom
    Ischemic chest pain + anterior STEMI ECG → emergent cath within 90 min
    ischemic_chest_pain_with_anterior_ecg
  • history
    New severe LV dysfunction on bedside echo + anterior wall akinesia
    lvef_drop_post_anterior_mi

Required inputs (7)

  • agerequired
    demographic • used at CONTEXT
    Older anterior MI patients higher mortality + LV thrombus risk
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + anterior MI → cardiogenic shock high probability (SCAI 2022)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    V1–V6 ST↑ defines anterior wall; localizes proximal-LAD vs distal-LAD per leads involved (V1-V2 → septal/proximal LAD; V3-V4 → apical; V5-V6 → lateral extension)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Peak troponin proportional to infarct size; anterior MIs typically have higher peaks → larger infarct → worse outcomes (4th UDMI 2018)
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + dosing; eGFR for DOAC after PCI
  • echo_post_pcirequired
    imaging • used at MONITORING
    LVEF + anterior wall motion + LV thrombus screen — repeat at 5-7 d for thrombus development (peaks day 3-7 post-anterior-MI)
  • cor_angiorequired
    imaging • used at TREATMENT
    LAD culprit confirmation + lesion location (proximal vs distal) drives prognosis + complete revasc decision (COMPLETE PMID 31475795)

12-phase flow (10)

  1. 1FRAME
    Anterior STEMI = LAD culprit; large-territory infarct; high LV failure + thrombus + ICD-eligibility risk; route immediately to cardio.stemi.core.v1 for the reperfusion arc
    inputs: ecg
    advance: anterior STEMI confirmed on ECG
  2. 2ENTRY
    Cath lab within 90 min; bedside echo for LVEF + RV strain + tamponade exclusion
    inputs: age
    advance: cath lab activated
  3. 3CONTEXT
    Allergies, bleed risk, recent surgery, antithrombotic regimen — same as parent
    inputs: sbp, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock (SCAI 2022 C+ — anterior STEMI is the most common shock cause; DanGer Shock PMID 38587234 Impella benefit); mechanical complications (papillary rupture, VSR — septal more common in anterior, free-wall more common in inferior)
    inputs: sbp
    actions: cardiogenic_shock
    advance: shock risk screened
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + CBC + CXR + bedside echo (LV function, anterior akinesia, RV, valvular)
    inputs: ecg, troponin, creatinine, echo_post_pci
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Primary PCI of LAD lesion; complete revasc per COMPLETE if multivessel; bypass surgery only if PCI not feasible
    inputs: cor_angio
    advance: reperfusion delivered
  7. 7TREATMENT
    Standard ACS regimen (ASA + ticagrelor + UFH + statin + BB if EF↓) per cardio.stemi.core.v1; ADD: high-vigilance LV thrombus screen at 5-7 d (anterior MI thrombus rate ≈ 25% if EF <40 + apical akinesia per Asinger NEJM 1981 historical + meta-analyses); WCD bridge if EF <35 → ICD at 40-90 d per MADIT-II
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion + secondary-prevention bundle started
  8. 8DISPOSITION
    CICU post-PCI; longer monitoring than inferior MI given complication profile
    advance: unit assigned + thrombus-screen plan documented
  9. 9MONITORING
    Telemetry, daily exam for new murmur (papillary or VSR); echo at 5-7 d for thrombus; echo at 40 d for LVEF reassessment + ICD eligibility
    inputs: echo_post_pci
    actions: panel.cardiac
    advance: thrombus + ICD timeline documented
  10. 10FOLLOWUP
    Cardiology + EP follow-up; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); WCD bridge during interval if EF <35; cardiac rehab
    advance: ICD/WCD pathway + cardiac rehab booked