Patient handout

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

PRODUCTION

1. Your condition

This handout is for late-presenter stemi (>12 h after symptom onset). Your care team identified this based on: ischemic chest pain with onset >12 h ago + persistent st elevation.

Other reasons your team may use this plan: persistent st elevation + evolving q waves on ecg (late stemi); delayed presentation (>12 h) with ongoing chest pain or hemodynamic instability — reperfusion still indicated.

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	PO	load + 81 mg daily indefinitely	AHA 2025 ACS Class I — secondary prevention regardless of reperfusion decision
ticagrelor	180 mg load → 90 mg BID	PO	BID × 12 mo if PCI performed	PLATO PMID 19717846; only if PCI performed
clopidogrel	300 mg load → 75 mg daily	PO	daily × 12 mo if no PCI but late STEMI with persistent ECG changes	OMT-only late STEMI: ASA + clopidogrel for secondary prevention per ACC/AHA 2025
atorvastatin	80 mg	PO	daily indefinitely	PROVE-IT PMID 15007110; high-intensity statin regardless of reperfusion
carvedilol	3.125 mg BID titrate	PO	BID	CAPRICORN PMID 11356436 — post-MI BB benefit independent of reperfusion
warfarin	5 mg daily; INR 2-3 × 3 mo	PO	daily	Late presenters have higher LV thrombus / aneurysm rate; AHA 2022 Class IIa 3-mo AC
tenecteplase	half-dose if age ≥75 (STREAM-2); standard weight-based otherwise	IV	single bolus	STREAM-2 (Armstrong 2020) — half-dose TNK in elderly; only when PCI not feasible AND ongoing ischemia

Plan: Late-presenter STEMI temporal phenotype — adds to parent cardio.stemi.core.v1 regimen if reperfusion indicated; otherwise OMT-only with secondary prevention bundle

3. When to call your provider

Contact your care team if any of the following happen:

ICD therapy delivered → urgent EP
EF declining despite the four foundational heart-failure medications → advanced HF eval

4. When to seek emergency care

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

Late-presenter STEMI + SBP <90 + lactate ≥2 + hypoperfusion — SCAI C+ at presentation(life-threatening)
New harsh holosystolic murmur OR pericardial effusion on echo OR sudden hemodynamic deterioration → free-wall rupture / VSR / papillary rupture (peak risk 3-7 d post-MI, more common in late presenters who never reperfused)(life-threatening)
LV thrombus on echo at 5-7 d post late STEMI — markedly higher rate in late presenters with anterior territory + EF <40 + apical akinesia
Late-presenter STEMI with developed ventricular aneurysm (typically anterior, apical) + mural thrombus on cardiac MRI / echo

5. Follow-up

Cardiology + EP follow-up; heart pumping strength (LVEF) re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab; secondary prevention bundle maintenance

6. Sources

Guideline: 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + OAT trial framework for late presenters