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cardio.stemi.antiphospholipid-syndrome-related.v1

STEMI — antiphospholipid syndrome related (arterial APS thrombosis)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E rare-etiology variant of cardio.stemi.core.v1 — STEMI in antiphospholipid syndrome (arterial APS thrombosis). Triple-positive APS (LA + aCL + β2-GPI) carries highest arterial-event risk. Inherits acute reperfusion + DAPT + statin from parent. Specializes long-term AC: WARFARIN INR 2.5-3.5 (NOT DOAC per TRAPS PMID 30196097) + concurrent low-dose ASA LIFELONG + consider HCQ adjunct. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent. Authored 2026-05-15 by shard-06-cardio-acute. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (3)

  • imaging
    ST elevation on ECG in patient with known APS or triple-positive antibody profile
    ecg_st_elevation_in_known_aps
  • symptom
    STEMI in young patient (<50) with prior venous thrombosis or pregnancy losses → APS suspect
    stemi_in_young_woman_with_recurrent_thrombosis
  • history
    Coronary cath shows thrombus burden disproportionate to atherosclerotic plaque → thrombophilia workup
    cath_thrombus_disproportionate_to_plaque

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Younger STEMI patients (<50) with thrombosis history raise APS suspicion
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic stratification + shock screen
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    STEMI territory localization; identical to parent
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Infarct sizing + serial trend
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy + warfarin/DOAC dosing
  • lupus_anticoagulant
    lab • used at BRANCHING_WORKUP
    APS criterion lab — must be drawn BEFORE heparin/warfarin (heparin invalidates LA assay) OR repeat ≥12 wk after AC washout
  • anticardiolipin_ab
    lab • used at BRANCHING_WORKUP
    IgG + IgM aCL ≥40 GPL/MPL or >99th percentile on 2 occasions ≥12 wk apart per Sydney criteria
  • beta2_glycoprotein_ab
    lab • used at BRANCHING_WORKUP
    IgG + IgM β2-GPI >99th percentile on 2 occasions ≥12 wk apart per Sydney criteria
  • cor_angiorequired
    imaging • used at TREATMENT
    May show fresh thrombus disproportionate to plaque; aspiration thrombectomy may be useful adjunct in this subset

12-phase flow (10)

  1. 1FRAME
    STEMI in patient with known APS or thrombosis pattern raising APS suspicion; coronary thrombosis (often more thrombus than plaque) is presenting feature
    inputs: ecg
    advance: STEMI confirmed + APS suspicion or prior dx noted
  2. 2ENTRY
    Cath lab activation within 90 min identical to parent; document APS history + current AC regimen
    inputs: age
    advance: cath lab activated
  3. 3CONTEXT
    Prior thrombosis (arterial/venous), pregnancy losses, autoimmune comorbidity (SLE 30-50% APS overlap), recent AC interruption (frequent APS thrombosis trigger)
    inputs: sbp, creatinine
    advance: APS context catalogued
  4. 4RED_FLAGS
    Catastrophic APS (CAPS) — multi-organ thrombosis in <1 wk + histopathology — mortality 50% without aggressive triple therapy (AC + steroids + plasma exchange/IVIG)
    inputs: sbp
    actions: cardiogenic_shock
    advance: CAPS screened + shock screened
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + CBC + bedside echo identical to parent; ADD: aPTT (LA may prolong baseline aPTT), D-dimer, fibrinogen
    inputs: ecg, troponin, creatinine
    actions: acs_pathway, panel.cardiac, panel.renal, panel.coag
    advance: workup documented
  6. 6BRANCHING_WORKUP
    APS confirmatory labs — DRAW BEFORE warfarin start OR plan to repeat ≥12 wk after AC washout (warfarin invalidates LA; DOAC also affects LA — must use mixing studies + dilute Russell viper venom time); SLE workup if unknown
    inputs: lupus_anticoagulant, anticardiolipin_ab, beta2_glycoprotein_ab
    advance: APS labs drawn or scheduled per AC timing
  7. 7TREATMENT
    Acute STEMI bundle identical to parent (ASA + P2Y12 + UFH + statin + cath/PCI); aspiration thrombectomy may have role given thrombus-predominant lesion; AVOID DOAC long-term per TRAPS (PMID 30196097); plan WARFARIN INR 2.5-3.5 transition + concurrent ASA continued
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion + LMWH/UFH bridge to warfarin started
  8. 8DISPOSITION
    CICU post-PCI; rheumatology + hematology consults for APS/thrombophilia management
    advance: unit + consult plan documented
  9. 9MONITORING
    Serial troponin, telemetry, INR daily during warfarin initiation (target 2.5-3.5 for arterial APS), reinforce LIFELONG AC + adherence (interruption = thrombosis trigger)
    actions: panel.cardiac, panel.coag
    advance: INR therapeutic + AC plan documented
  10. 10FOLLOWUP
    Cardiology + rheumatology + hematology multidisciplinary follow-up; lifelong warfarin INR 2.5-3.5 + ASA; hydroxychloroquine if SLE overlap (may reduce APS thrombosis); avoid OCPs/HRT (estrogen worsens APS)
    advance: multidisciplinary plan + AC adherence pathway booked