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cardio.stemi.core.v1

STEMI / OMI (acute coronary syndrome)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Stepwise regimen (Step 1 ED bundle → 2A primary PCI → 2B fibrinolysis → 3 cardiogenic shock with 4-territory phenotype map → 4 territory-aware GDMT) authored with RxCUIs sourced from cardio.stemi.core.v1.atoms.treatment.ts; per-setting playbooks (ED → ICU → inpatient → transition → outpatient) capture timing thresholds and disposition criteria. Severity triggers fire fibrinolysis when DTB at risk, MCS escalation in shock, emergency surgery for mechanical complication, amiodarone for VT/VF, rescue PCI for failed lysis, and RV-infarct nitrate-avoidance. NSTEMI does NOT exist as a separate dossier (cardio.nstemi.core.v1 not authored) — flagged in sibling_differentiation; for now route NSTE-ACS via calc.heart/calc.timi_nstemi/calc.grace triage to chronic_coronary_syndrome.outpatient. STREAM-2 (half-dose TNK in elderly), REDUCE-AMI (β-blocker preserved EF nuance), PEGASUS, DAPA-MI, COMPLETE, FULL REVASC, DanGer Shock, ECLS-SHOCK, VALIDATE-SWEDEHEART, MATRIX, HORIZONS-AMI, SOAP-II, EXTRACT-TIMI 25, STREAM, HOST-EXAM, SMART-CHOICE, PARADISE-MI, IMPROVE-IT, FOURIER, BIOSTEMI, AVOID, COGENT, CAPRICORN, GISSI-3, SAVE, AIRE, EPHESUS, PLATO, TRITON-TIMI 38, CLARITY-TIMI 28, REACT, GUSTO-I, SCAI 2022, ACC/AHA 2022 Chest Pain, 4th UDMI 2018, and DOSE all anchored in evidence.pmids[] post-deepening. Deepening pass 2026-05-14 (shard-06-cardio-acute) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 contract items 1+2; (2) STEMI ddx + finding-lrs seed files; (3) transition + outpatient setting playbooks (5 total); (4) calc.timi_stemi + calc.grace as required band-mapped calculators (8 total); (5) territory phenotype encoding in regimen Step 3 + 4 labels (anterior-LAD / inferior-RCA-RV / posterior-LCx / LMCA-equivalent / post-arrest STEMI); (6) PMID array expanded from 15 → 47. Citation + RxCUI safety sweep 2026-05-24 (live-verified every PMID via PubMed esummary and every RxCUI via RxNav property.json): corrected the previously-flagged morphine RxCUI (now 7052, distinct from norepinephrine 7512) and ezetimibe RxCUI (now 341248); additionally fixed 12 more wrong/invalid drug codes (nitroglycerin 4917, heparin 235473, bivalirudin 60819, tenecteplase 259280, alteplase 8410, milrinone 52769, evolocumab 1665684, prasugrel 613391, lisinopril 29046, sacubitril/valsartan 1656339, amiodarone 703, pantoprazole 40790) and 26 fabricated PMIDs across evidence.pmids[] and inline rationale prose (duplicate FULL REVASC entry collapsed to one).

Entry points (4)

  • symptom
    Ischemic chest pain / anginal equivalent (ACC/AHA 2025 Class I)
    ischemic_chest_pain
  • imaging
    ECG STEMI / OMI / Sgarbossa+ / de Winter / Wellens (ESC 2023; Sgarbossa NEJM 1996; de Winter NEJM 2008)
    ecg_st_elevation
  • lab_abnormality
    Rising troponin in ischemic context (4th Universal Definition of MI 2018)
    troponin_rising
  • symptom
    Post-arrest ROSC with ischemic ECG (ACC/AHA 2025 Class I)
    cardiac_arrest_rosc

Required inputs (13)

  • agerequired
    demographic • used at TREATMENT
    STREAM-2 half-dose TNK in elderly ≥75 yo + reperfusion strategy (ACC/AHA 2025)
  • sbprequired
    vital • used at RED_FLAGS
    Cardiogenic shock screen per SCAI staging; nitrate contraindication if RV infarct (ACC/AHA 2025 Class III)
  • hrrequired
    vital • used at CONTEXT
    Bradyarrhythmia in inferior MI; β-blocker timing per REDUCE-AMI 2024 + CAPRICORN
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Diagnostic per ACC/AHA 2025 Class I; localizes infarct territory (anterior, inferior, RV, posterior, LMCA, LBBB-equiv)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    4th Universal Definition of MI 2018; serial trending per ESC 2023
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + DOAC + enoxaparin dosing per EXTRACT-TIMI 25 2006
  • potassiumrequired
    lab • used at CONTEXT
    Reperfusion arrhythmia prevention (K + Mg) per ACC/AHA 2025 Class I
  • magnesium
    lab • used at CONTEXT
    Pre-reperfusion repletion per ACC/AHA 2025
  • lactate
    lab • used at RED_FLAGS
    Cardiogenic shock SCAI staging (Baran et al 2019)
  • allergies
    history • used at CONTEXT
    Aspirin / contrast / antiplatelet allergies per ACC/AHA 2025 safety check
  • bleeding_history
    history • used at TREATMENT
    DAPT bleed risk (HAS-BLED) + fibrinolysis contraindication per ACC/AHA 2025 Class III
  • recent_stroke_or_surgery
    history • used at TREATMENT
    Fibrinolysis absolute / relative contraindication per ACC/AHA 2025 Table 6
  • cocaine_use
    history • used at CONTEXT
    Cocaine-related ACS — benzo first; AVOID β-blocker monotherapy acute per ACC/AHA 2025 Class III

12-phase flow (10)

  1. 1FRAME
    STEMI = time-critical reperfusion per ACC/AHA 2025 Class I; OMI paradigm — treat occluded artery on ECG even without classical ST criteria (Meyers et al 2019)
    inputs: ecg
    advance: STEMI / OMI / fibrinolysis-eligible diagnosis confirmed
  2. 2ENTRY
    Capture chest-pain or equivalent + ECG trigger per ACC/AHA 2025 — ECG within 10 min of arrival
    inputs: age
    advance: STEMI alert called
  3. 3CONTEXT
    Allergies, bleeding history, recent surgery / stroke, cocaine, anticoagulation, comorbidity per ACC/AHA 2025 pre-reperfusion checklist
    inputs: sbp, hr, creatinine, potassium, allergies, cocaine_use
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock (SHOCK trial 1999), RV infarct (avoid nitrates per ACC/AHA Class III), VT/VF arrest, mechanical complication
    inputs: sbp, lactate
    actions: cardiogenic_shock, wide_complex_tach, acute_valvular_emergency
    advance: high-risk subsets routed
  5. 5INITIAL_WORKUP
    ECG, serial troponin, BMP/Mg, CBC, coag, type-and-screen, CXR, echo when stable per ACC/AHA 2025 Class I
    inputs: ecg, troponin, creatinine, potassium
    actions: panel.cardiac, panel.renal, panel.coag, acs_pathway, chest_pain
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Activate cath lab per ACC/AHA 2025 Class I; if no PCI in 120 min, fibrinolysis (TNK or STREAM-2 half-dose for ≥75 yo); transfer for rescue PCI if fibrinolysis fails (REACT 2005)
    advance: reperfusion strategy chosen
  7. 7RISK_STRATIFICATION
    TIMI-STEMI (Morrow et al 2000) / GRACE; SCAI for shock (Baran et al 2019); Sgarbossa / de Winter / Wellens / OMI flag
    inputs: age, sbp, creatinine
    actions: calc.timi_nstemi, calc.heart
    advance: risk class documented
  8. 8TREATMENT
    ASA 162–325 chewed (ACC/AHA 2025 Class I) + ticagrelor (PLATO) / prasugrel (TRITON-TIMI 38) preferred or clopidogrel; UFH or bivalirudin (HORIZONS-AMI) or enoxaparin; primary PCI within 90 min DTB (radial preferred); complete revasc (COMPLETE trial); β-blocker if reduced EF (CAPRICORN; REDUCE-AMI 2024 nuance); high-intensity statin + ezetimibe (IMPROVE-IT) + PCSK9i (FOURIER) to LDL <55; ACEi for LV dysfunction (SAVE/AIRE); SGLT2i (DAPA-MI); MRA if reduced EF (EPHESUS); PPI on DAPT (COGENT)
    inputs: sbp, hr, creatinine
    actions: protocol.stemi
    advance: reperfusion delivered + secondary prevention bundle started before discharge
  9. 9DISPOSITION
    CCU per ACC/AHA 2025; cardiogenic shock → MCS-capable center (DanGer Shock 2024); cardiac rehab referral Class I
    advance: unit + rehab referral assigned
  10. 10MONITORING
    Telemetry per ACC/AHA 2025; serial troponin / BMP; LV function reassessment 40–90 d post-MI for ICD eligibility (ACC/AHA Class I)
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring plan documented