cardio.stemi.in-pregnancy-non-scad.v1

STEMI in pregnancy — non-SCAD etiology (atherosclerotic / embolic / thrombotic)

cardiologyacuteadultacuteinpatienttransitionoutpatient

Start encounter →Print handoutPRODUCTION

Phase E rare-etiology variant of cardio.stemi.core.v1 — STEMI in pregnancy, NON-SCAD etiology (atherosclerotic/embolic/thrombotic/vasospastic/takotsubo). Distinguished from cardio.stemi.scad.v1 which covers peripartum SCAD. Inherits acute reperfusion + DAPT framework from parent. Specializes pregnancy-modified pharmacology: clopidogrel preferred over ticagrelor, UFH preferred over LMWH peri-cath, AVOID warfarin/atenolol/ACEi/ARB/statin (case-by-case), FIBRINOLYSIS CONTRAINDICATED. 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 pregnant patient (any trimester) or postpartum ≤6 wk
ecg_stemi_in_pregnancy
symptom
Ischemic chest pain in pregnant patient → urgent workup; differential includes SCAD, PE, aortic dissection, takotsubo
ischemic_chest_pain_pregnancy
history
Chest pain in postpartum patient ≤6 wk (peak hypercoagulable + hemodynamic risk window)
postpartum_acs_first_6_weeks

Required inputs (9)

agerequired
demographic • used at CONTEXT
Older maternal age (>35) + IVF era → atherosclerotic STEMI more common in pregnancy than historical
gestational_agerequired
demographic • used at CONTEXT
Drives radiation/medication risk profile; peri/postpartum window highest risk
sbprequired
vital • used at RED_FLAGS
Hemodynamic stratification + shock screen; pregnancy hemodynamics complex
ecgrequired
imaging • used at INITIAL_WORKUP
STEMI territory localization; identical to parent
troponinrequired
lab • used at INITIAL_WORKUP
Infarct sizing; troponin remains gold standard in pregnancy (NOT elevated by physiologic pregnancy)
creatininerequired
lab • used at CONTEXT
Contrast nephropathy + medication dosing; pregnancy GFR ↑ 50% so absolute Cr lower than baseline
urine_drug_screen
lab • used at INITIAL_WORKUP
Cocaine + sympathomimetics can cause STEMI in pregnancy; impacts treatment + delivery planning
cor_angiorequired
imaging • used at TREATMENT
Emergent cath with abdominal shielding (radiation 10-50× lower than CT-PE); essential for distinguishing SCAD vs plaque vs embolus vs vasospasm
echo_post_pcirequired
imaging • used at MONITORING
LV function + RV strain (PE differential) + valvular + thrombus screen

12-phase flow (10)

1FRAME
STEMI in pregnant or ≤6 wk postpartum patient — DISTINGUISH from SCAD (separate engine cardio.stemi.scad.v1) by cath findings; this engine covers atherosclerotic, embolic, thrombotic, vasospastic, takotsubo etiologies
inputs: ecg, gestational_age
advance: STEMI confirmed + pregnancy/postpartum status documented
2ENTRY
Cath lab activation within 90 min — ABDOMINAL SHIELDING + minimize fluoro time; OB consult immediately for fetal monitoring + delivery planning
inputs: age, gestational_age
advance: cath lab activated + OB consulted
3CONTEXT
Trimester, prior pregnancies, prior loss, hypertensive disorders of pregnancy (preeclampsia ↑ ACS risk), IVF history, drug use, family hx CAD, autoimmune (APS overlap)
inputs: sbp, creatinine
advance: pregnancy + cardiac context catalogued
4RED_FLAGS
Cardiogenic shock; PE differential (D-dimer unreliable in pregnancy); aortic dissection (pregnancy + connective tissue disease); fetal distress requiring emergent delivery; cocaine intoxication
inputs: sbp
actions: cardiogenic_shock, chest_pain
advance: differential narrowed + shock + fetal status screened
5INITIAL_WORKUP
ECG + troponin + BMP + CBC + bedside echo + fetal monitoring (continuous if ≥24 wk + viable); urine drug screen; hold CT-PE unless essential (use shielded cath/echo first)
inputs: ecg, troponin, creatinine, urine_drug_screen
actions: acs_pathway, panel.cardiac, panel.renal
advance: workup documented + fetal monitoring established
6BRANCHING_WORKUP
Cath findings drive etiology classification: SCAD → route to cardio.stemi.scad.v1; plaque rupture → atherosclerotic management; thrombus → APS/thrombophilia workup → route to cardio.stemi.antiphospholipid-syndrome-related.v1 if positive; embolism → echo for source; vasospasm/takotsubo → conservative management
inputs: cor_angio
advance: etiology classified
7TREATMENT
Acute STEMI bundle MODIFIED for pregnancy: ASA Class B (continue), CLOPIDOGREL preferred over ticagrelor (data limited), UFH preferred over LMWH peri-cath (reversibility), AVOID statin (FDA Class X — hold or use only if absolute necessity + SDM), AVOID warfarin (teratogen + fetal hemorrhage), AVOID atenolol (FGR), use metoprolol/labetalol if BB needed, FIBRINOLYSIS CONTRAINDICATED (ICH + placental abruption)
inputs: sbp, creatinine
actions: protocol.stemi
advance: pregnancy-modified reperfusion + AC bundle started
8DISPOSITION
CICU + MFM (maternal-fetal medicine) co-management; consider fetal monitoring continuous if ≥24 wk; delivery planning multidisciplinary
advance: unit + MFM + neonatology consult booked
9MONITORING
Telemetry, fetal monitoring per gestational age, daily exam; serial echo for thrombus + LV function; OB monitoring for preeclampsia (overlapping risk)
inputs: echo_post_pci
actions: panel.cardiac
advance: maternal + fetal monitoring stable
10FOLLOWUP
Multidisciplinary cardiology + MFM + lactation: vaginal delivery preferred unless obstetric/cardiac indication; postpartum revascularization if not done acutely; lactation safe meds (avoid amiodarone, ACEi okay postpartum); statin restart 6 wk postpartum if not breastfeeding (or use pravastatin-only if breastfeeding per limited data); contraception planning (avoid estrogen — IUD/progestin preferred)
advance: delivery plan + postpartum medication plan + contraception booked