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cardio.stemi.late-presenter.v1

Late-presenter STEMI (>12 h after symptom onset)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E temporal-context variant of cardio.stemi.core.v1 — narrowed to STEMI presenting >12 h after symptom onset. Decision axis: ongoing ischemia / shock / arrhythmia → emergent reperfusion (Class I); asymptomatic 12-72 h + viable myocardium on cardiac MRI / dobutamine stress / PET → IIa delayed PCI; >72 h asymptomatic stable → OMT only per OAT (PMID 17112106). Higher rate of LV thrombus, ventricular aneurysm, and mechanical complications (free-wall rupture, VSR, papillary rupture) — peak 3-7 d post-MI. Aggressive thrombus screen at 5-7 d echo + daily murmur surveillance. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (late-presenter-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (3)

  • symptom
    Ischemic chest pain with onset >12 h ago + persistent ST elevation
    chest_pain_onset_greater_than_12h
  • imaging
    Persistent ST elevation + evolving Q waves on ECG (late STEMI)
    ecg_persistent_st_elevation_with_qwaves
  • history
    Delayed presentation (>12 h) with ongoing chest pain or hemodynamic instability — reperfusion still indicated
    delayed_presentation_with_ongoing_symptoms

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Elderly more likely to be late presenters; STREAM-2 half-dose TNK considerations
  • symptom_onset_timerequired
    history • used at FRAME
    Time-from-onset is the central decision axis: <12 h → emergent PCI; 12-72 h asymptomatic + viable → IIa PCI; >72 h asymptomatic stable → OMT only (OAT)
  • ongoing_ischemiarequired
    symptom • used at RED_FLAGS
    Persistent / recurrent chest pain or dynamic ECG → reperfusion still Class I regardless of time window
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension / shock → emergent reperfusion regardless of time window (SCAI 2022)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Persistent ST elevation vs evolved Q-waves drives reperfusion decision; rapidly evolving Q-waves → completed infarction with less viability
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Trajectory (rising vs peaked-and-falling) helps localize where in the infarct timeline patient sits
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk for cath + DOAC dosing post-MI
  • echo_post_admissionrequired
    imaging • used at INITIAL_WORKUP
    Bedside echo: LVEF, regional wall motion, LV thrombus (more common in late presenters), aneurysm, mechanical complications
  • viability_imaging
    imaging • used at BRANCHING_WORKUP
    Cardiac MRI with LGE / dobutamine stress echo / PET — for asymptomatic 12-72 h presenters to identify candidates for delayed PCI; viable myocardium >50% supplies revascularization benefit

12-phase flow (10)

  1. 1FRAME
    Late-presenter STEMI = symptom onset >12 h ago. Decision axis: ongoing ischemia / shock / arrhythmia → emergent reperfusion (Class I); asymptomatic 12-72 h + viable myocardium → IIa delayed PCI; >72 h asymptomatic stable → OMT only per OAT
    inputs: symptom_onset_time
    advance: time-from-onset stratification documented
  2. 2ENTRY
    Triage by symptom + hemodynamic + arrhythmia status; bedside echo for shock + mechanical complication exclusion
    inputs: age, sbp
    advance: triage stratum assigned
  3. 3CONTEXT
    Allergies, bleed risk, recent surgery, antithrombotic regimen, frailty (late presenters skew older)
    inputs: creatinine
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock (SCAI 2022 — emergent PCI Class I regardless of time); life-threatening arrhythmia; mechanical complications (free-wall rupture, VSR, papillary rupture — all more common in late presenters)
    inputs: sbp, ongoing_ischemia
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    ECG (persistent ST↑ vs Q-wave completion), troponin trajectory, BMP, CBC, CXR, bedside echo (LV thrombus, aneurysm, regional wall motion)
    inputs: ecg, troponin, creatinine, echo_post_admission
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    For asymptomatic 12-72 h: viability imaging (cardiac MRI with LGE preferred; dobutamine stress echo / PET alternatives) → if viable myocardium >50% of territory, IIa delayed PCI; for >72 h asymptomatic stable, no PCI per OAT (PMID 17112106)
    inputs: viability_imaging
    advance: reperfusion decision made
  7. 7TREATMENT
    If indicated: standard ACS regimen via cardio.stemi.core.v1 (ASA + P2Y12 + UFH + statin + BB if EF↓); if NOT indicated for PCI: OMT with full secondary prevention; ALL late presenters get aggressive LV thrombus screen (5-7 d echo) + GDMT initiation if EF reduced
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion decision executed + secondary prevention started
  8. 8DISPOSITION
    CICU if shock / arrhythmia / mechanical complication / post-PCI; cardiology floor if stable + no PCI
    advance: unit assigned + reperfusion plan documented
  9. 9MONITORING
    Telemetry, daily exam for new murmur (mechanical complications), echo at 5-7 d for LV thrombus screen, echo at 40 d for LVEF reassessment + ICD eligibility
    inputs: echo_post_admission
    actions: panel.cardiac
    advance: thrombus + ICD timeline documented
  10. 10FOLLOWUP
    Cardiology + EP follow-up; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab; secondary prevention bundle maintenance
    advance: ICD/WCD pathway + cardiac rehab booked