Patient handout

STEMI — Behçet-disease-associated coronary vasculitis (variable-vessel vasculitis with aneurysms + thrombosis)

PRODUCTION

1. Your condition

This handout is for stemi — behçet-disease-associated coronary vasculitis (variable-vessel vasculitis with aneurysms + thrombosis). Your care team identified this based on: stemi in patient with established behçet disease — coronary vasculitis vs aneurysm thrombosis vs spasm triage.

Other reasons your team may use this plan: stemi in young man (20-40 yr; mediterranean / silk road origin) with recurrent oral + genital ulcers + uveitis + skin lesions → de novo behçet consideration; coronary cath shows aneurysmal coronary segments (saccular, mycotic-like appearance) with intra-aneurysmal thrombus → variable-vessel vasculitis suspect; avoid fibrinolysis given rupture risk; stemi with concurrent dvt / pe / large-vessel arterial aneurysm (pulmonary, aortic) — vasculo-behçet subtype with arterial + venous involvement.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
aspirin	162-325 mg chewed load → 81 mg daily lifelong	PO	daily indefinitely	AHA 2025 ACS Class I + EULAR 2018 (PMID 29625968) — ASA in BD arterial event with thrombus; AVOID aspirin MONOTHERAPY as sole antithrombotic in pure-vasculitic phenotype (does not address inflammation)
ticagrelor	180 mg load → 90 mg BID	PO	BID × 12 mo standard DAPT, then reassess given vasculitis status	PLATO PMID 19717846; standard ACS DAPT applies; duration extension if persistent vasculitis activity or recurrent thrombus
unfractionated_heparin	70-100 U/kg IV bolus + activated infusion	IV	bolus + infusion at PCI	AHA 2025 Class I for PCI; UFH preferred over LMWH given more reversible if aneurysm bleeding complication
atorvastatin	80 mg daily lifelong	PO	daily	PROVE-IT PMID 15007110; high-intensity statin lifelong post-MI; pleiotropic anti-inflammatory effect particularly relevant for BD endothelial dysfunction
colchicine	0.5-1 mg PO daily (Mediterranean fever dose); 0.6 mg BID alternative	PO	daily lifelong	EULAR 2018 (PMID 29625968) Class I — colchicine foundational for ALL BD patients; mucocutaneous + arthritis benefit + modest vascular benefit; renal-adjusted; eGFR <30 contraindicated for chronic use
methylprednisolone	1 g IV daily × 3 days	IV	pulse × 3 d	EULAR 2018 (PMID 29625968) Class I — pulse steroids for severe / vital-organ vasculo-Behçet including coronary vasculitis; bridge to oral prednisone + steroid-sparing agent
prednisone	1 mg/kg PO daily, taper over months	PO	daily with taper schedule	EULAR 2018 (PMID 29625968) — oral steroid taper after pulse; goal is steroid minimization with steroid-sparing agent (azathioprine / MMF / TNF-α inhibitor)
cyclophosphamide	500-1000 mg/m² IV monthly × 6 (or low-dose Euro-Lupus 500 mg q2w × 6)	IV	monthly × 6	EULAR 2018 (PMID 29625968) Class I — cyclophosphamide for severe / vital-organ vasculo-Behçet; coronary + pulmonary artery aneurysms qualify; gonadotoxic — counseling required
infliximab	5 mg/kg IV at 0, 2, 6 weeks then q6-8 weeks	IV	q6-8 weeks	EULAR 2018 (PMID 29625968) — TNF-α inhibitor (infliximab or adalimumab) for refractory severe BD; Sfikakis 2004 (PMID 15571742) supports use; screen for latent TB + hepatitis pre-initiation
azathioprine	2-3 mg/kg/d PO; check TPMT before initiation	PO	daily	Hamuryudan 2004 (PMID 14730108) — azathioprine reduces eye disease + vascular events in BD; foundational maintenance steroid-sparing agent
mycophenolate_mofetil	1-3 g/d divided BID	PO	BID	EULAR 2018 — MMF alternative steroid-sparing maintenance; teratogenic — switch off before conception
warfarin	5 mg daily; INR target 2-3 ONLY if clear thrombus burden + concurrent immunosuppression; AVOID in pure-vasculitic without thrombus given aneurysm rupture risk	PO	daily	EULAR 2018 (PMID 29625968) — AC controversial in BD; immunosuppression is primary therapy for vasculo-Behçet vascular events; AC ONLY with concurrent immunosuppression and clear thrombus; aneurysm rupture risk; venous thrombosis treated with immunosuppression rather than AC alone in BD
carvedilol	3.125 mg BID titrate	PO	BID	CAPRICORN PMID 11356436 — post-MI BB benefit; carvedilol preferred for HFrEF GDMT
sacubitril-valsartan	24/26 mg BID titrate	PO	BID	PIONEER-HF PMID 30403955; ACC/AHA 2022 HF Class I if HFrEF persists post-MI

Plan: Behçet coronary vasculitis + STEMI regimen — combines acute reperfusion (PCI ONLY, NO lysis) with high-dose immunosuppression and lifelong colchicine + maintenance immunosuppression + secondary prevention

3. When to call your provider

Contact your care team if any of the following happen:

New ACS or recurrent CAD on CTA → cardiology + rheumatology — assess vasculitis activity vs atherosclerosis
New or growing extra-coronary aneurysm → vascular surgery + escalate immunosuppression
Pulmonary artery aneurysm with hemoptysis → emergent thoracic surgery + escalate immunosuppression
EF declining despite the four foundational heart-failure medications → advanced HF / transplant evaluation
Bleeding on DAPT ± AC → reassess regimen
BD flare → rheumatology — escalate immunosuppression
Pregnancy planned → switch teratogenic meds 3 mo prior + high-risk obstetrics + cardiology team
Smoking relapse → enhanced cessation support — major vasculo-Behçet flare risk

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

IVUS/OCT confirms vessel-wall inflammation + aneurysm with thrombus + active BD features (mucocutaneous, ocular, vascular, elevated ESR/CRP) at index STEMI → high-dose pulse steroids + cyclophosphamide immediately; AVOID fibrinolysis (rupture risk)(life-threatening)
Massive hemoptysis + pulmonary artery aneurysm on CTA in BD patient → CHARACTERISTIC VASCULO-BEHÇET EMERGENCY; aneurysm rupture imminent or ongoing; mortality without rapid intervention(life-threatening)
Aortic / abdominal / splenic / renal aneurysm rupture with concurrent BD-STEMI → multi-organ vascular emergency; mortality high without simultaneous vascular surgery + cardiac care(life-threatening)
New CNS deficits (parenchymal — brainstem common; or vascular — cerebral venous thrombosis) + STEMI in BD patient → concurrent neuro-Behçet flare; immunosuppression must address both compartments(life-threatening)
EF <35 + non-sustained VT on telemetry post-BD-STEMI → SCD risk in 40-90 d window (often young patients with lifetime ICD implications)(life-threatening)
New fever / infiltrate / cytopenia during high-dose steroid + cyclophosphamide / TNF-α inhibitor — opportunistic infection (PJP, CMV, fungal, TB reactivation especially with TNF-α) high risk
Smoking relapse + new vascular event (DVT, arterial thrombosis, aneurysm enlargement) in BD patient — smoking is major vasculo-Behçet flare trigger

5. Follow-up

Lifelong colchicine; maintenance immunosuppression per rheumatology (azathioprine 2-3 mg/kg/d PO OR MMF 1-3 g/d OR TNF-α inhibitor); aggressive secondary prevention (high-intensity statin, BP control, no smoking — smoking is major vasculo-Behçet flare trigger); cardiology + rheumatology + ophthalmology q3 mo first year then q6 mo; surveillance CTA at 3-6 mo then annually for aneurysm; AVOID OCP / estrogen (procoagulant + may flare BD)

6. Sources

Guideline: 2025 ACC/AHA ACS Guideline + EULAR 2018 Behçet syndrome management recommendations (Hatemi ARD 2018 PMID 29625968) + International Study Group BD criteria (Lancet 1990 PMID 1970380) + Chapel Hill Consensus 2012 vasculitis nomenclature (PMID 23045170)