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cardio.stemi.kawasaki-related.v1

STEMI from prior Kawasaki disease coronary aneurysm / stenosis

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E etiology variant of cardio.stemi.core.v1 — STEMI from prior Kawasaki disease coronary aneurysm thrombosis or aneurysm-adjacent stenosis. Population: young adults (20-40s) with childhood KD history. Aneurysm risk: 15-25% if untreated KD, <5% with timely IVIG; giant aneurysms (≥8 mm or Z-score ≥10) carry highest thrombosis risk. INHERITS parent reperfusion + DAPT + statin pathway BUT OVERRIDES: anticoagulation duration (lifelong warfarin INR 2-3 if persistent giant aneurysm thrombus per AHA Kawasaki 2024 PMID 38683866 vs 3 mo for LV thrombus), revascularization technique (aneurysm-aware PCI / CABG), statin justification (lifelong per AHA Kawasaki regardless of LDL), and long-term surveillance modality (coronary CTA every 1-3 yr preferred over invasive cath). Critical care-setting issue: pediatric → adult congenital cardiology transition is a known failure point. Index event is opportunity to establish lifelong adult congenital cardiology relationship + KD specialist referral. Pregnancy counseling required for women (warfarin teratogenic — switch to LMWH if pregnancy planned). Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (3)

  • history
    Young adult (20-40s) with documented childhood Kawasaki disease history presenting with chest pain
    prior_kawasaki_disease_with_chest_pain
  • imaging
    ST elevation on ECG in patient with known persistent coronary aneurysm from KD — emergent cath
    ecg_st_elevation_with_known_giant_aneurysm
  • history
    Incidental giant coronary aneurysm finding on cardiac imaging in adult presenting with ACS — KD aneurysm presumed
    incidental_giant_aneurysm_finding_with_acs

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    KD-related STEMI typically presents in 20-40s — much younger than atherosclerotic ACS; raises pre-test probability for non-atherosclerotic cause
  • childhood_kawasaki_diseaserequired
    history • used at FRAME
    Documented childhood KD (with or without timely IVIG) is the central diagnostic anchor; aneurysm risk: 15-25% if untreated, <5% if IVIG within 10 days
  • prior_coronary_aneurysm_imagingrequired
    history • used at INITIAL_WORKUP
    Prior echo / cardiac MRI / CTA / cath imaging shows whether aneurysms persist, their size (giant ≥8 mm or Z-score ≥10), and which arteries — directly drives PCI vs CABG decision
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + STEMI in giant aneurysm patient → cardiogenic shock high probability
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    ST elevation territory localizes culprit aneurysm / stenosis
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Quantifies infarct burden + drives emergency reperfusion decision
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk for cath + DOAC dosing
  • cor_angiorequired
    imaging • used at TREATMENT
    Diagnostic + therapeutic gold standard; aneurysm anatomy + thrombus burden + multivessel involvement determines PCI vs CABG
  • tee
    imaging • used at BRANCHING_WORKUP
    TEE if giant aneurysm with concern for endocarditis (rare) or to characterize thrombus extent
  • echo_post_admissionrequired
    imaging • used at MONITORING
    LVEF + regional wall motion + aneurysm visualization (where coronary anatomy permits)

12-phase flow (10)

  1. 1FRAME
    KD-related STEMI = thrombosis or stenosis of a persistent post-KD coronary aneurysm in a young adult. Standard ACS reperfusion paradigm applies, BUT aneurysm anatomy changes PCI feasibility and long-term anticoagulation strategy.
    inputs: childhood_kawasaki_disease
    advance: KD-related etiology confirmed
  2. 2ENTRY
    Activate cath lab; pull prior coronary imaging from records; start emergent ACS pathway
    inputs: age
    advance: cath lab activated + prior imaging requested
  3. 3CONTEXT
    KD treatment history (IVIG yes/no, age at KD), prior coronary imaging modality / dates / findings, prior antiplatelet / AC regimen, allergies, bleed risk
    inputs: creatinine
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock (giant aneurysm with massive thrombus → large infarct), life-threatening arrhythmia, sudden cardiac death risk → emergent reperfusion + MCS team
    inputs: sbp
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + CBC + CXR + bedside echo (LV function + aneurysm visualization where possible); request prior coronary imaging from KD follow-up
    inputs: ecg, troponin, prior_coronary_aneurysm_imaging, echo_post_admission
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Emergent cath: characterize aneurysm anatomy, thrombus burden, multivessel involvement; consider TEE if giant aneurysm with thrombus extension concern; intracoronary imaging (IVUS / OCT) if anatomy ambiguous
    inputs: cor_angio, tee
    advance: aneurysm anatomy + thrombus + reperfusion strategy decided
  7. 7TREATMENT
    Emergent reperfusion: PCI (catheter thrombectomy + selective stenting; technically challenging across aneurysm); CABG if multivessel / giant-aneurysm anatomy where PCI infeasible; thrombolysis if PCI delayed >120 min and no contraindication. Triple therapy: ASA + P2Y12 + AC if persistent giant aneurysm with thrombus.
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion + antithrombotic regimen executed
  8. 8DISPOSITION
    CICU 48-72 h post-reperfusion; pediatric-cardiology / KD specialist consult for transition planning if not already in adult care
    advance: unit assigned + KD specialist referral booked
  9. 9MONITORING
    Telemetry, daily exam, echo at 5-7 d for thrombus / new aneurysm; coronary CTA at 4-6 weeks to reassess aneurysm anatomy post-event
    inputs: echo_post_admission
    actions: panel.cardiac
    advance: thrombus + aneurysm surveillance documented
  10. 10FOLLOWUP
    Lifetime ASA + statin; long-term AC if persistent giant aneurysm with thrombus; serial coronary CTA (preferred over invasive cath in stable patient); transplant referral if severe LV dysfunction; pregnancy + family planning counseling (for women); transition pediatric → adult congenital cardiology
    advance: long-term surveillance + congenital cardiology handoff complete