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cardio.stemi.left-main.v1

Left main coronary artery (LMCA) STEMI-equivalent

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.stemi.core.v1 — narrowed to LMCA / LMCA-equivalent STEMI defined by aVR ST↑ + diffuse ST↓ ≥6 leads pattern. Inherits reperfusion + antiplatelet + statin regimen from parent via routing; specializes REVASCULARIZATION CHOICE (CABG vs PCI per SYNTAX/EXCEL), DK-CRUSH technique for LMCA bifurcation PCI, very high CS probability requiring early MCS (Impella CP per DanGer Shock), and P2Y12-timing complexity (HOLD or cangrelor bridge if CABG decided). Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (LMCA-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as part of Phase E variant batch (inferior/RV/posterior/LMCA).

Entry points (3)

  • imaging
    aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads (LMCA equivalent / 3-vessel disease)
    ecg_avr_st_elevation_with_diffuse_depression
  • symptom
    Severe ischemic chest pain + hypotension/shock + LMCA-equivalent ECG → emergent cath + MCS standby
    severe_ischemic_chest_pain_with_hemodynamic_instability
  • history
    Known or newly identified LMCA lesion on angio in acute coronary syndrome
    lmca_lesion_on_angio_with_acute_presentation

Required inputs (8)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher peri-revasc mortality; informs PCI vs CABG decision per SYNTAX score interaction with age
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension highly prevalent — LMCA territory occlusion typically produces SCAI C-E shock; informs urgent MCS need
  • lactaterequired
    vital • used at RED_FLAGS
    Lactate ≥2 supports SCAI C+ shock staging — anchor for MCS escalation per DanGer Shock PMID 38587234
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads = LMCA-equivalent or proximal-LAD-pre-septal or 3VD; high mortality without urgent revasc
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Confirms infarct; LMCA-territory infarcts produce massive troponin rise reflecting large jeopardized myocardium
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy + DOAC dosing; CKD interacts with surgical-vs-PCI decision (CABG often preferred in CKD per SYNTAX subset)
  • echo_post_revascrequired
    imaging • used at MONITORING
    LV function (often severely depressed); RV function; mechanical complications
  • cor_angio_with_syntaxrequired
    imaging • used at TREATMENT
    LMCA lesion confirmation + SYNTAX score for CABG-vs-PCI decision; LMCA bifurcation morphology for DK-CRUSH technical planning

12-phase flow (10)

  1. 1FRAME
    LMCA STEMI-equivalent = aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads pattern; HIGH mortality without urgent revasc; cardiogenic shock typical; route to cardio.stemi.core.v1 for the reperfusion arc; CABG vs PCI decision is the dominant strategic question
    inputs: ecg
    advance: LMCA-equivalent ECG confirmed
  2. 2ENTRY
    Cath lab within 90 min OR direct surgical OR; bedside echo for LV/RV function; MCS team activation early given high CS probability
    inputs: age, sbp, lactate
    advance: cath/OR activated + MCS team alerted
  3. 3CONTEXT
    Allergies, bleed risk, recent surgery, CABG eligibility (frailty, comorbidity, prior CABG), antithrombotic regimen
    inputs: sbp, creatinine
    advance: context complete + revasc strategy team-discussed
  4. 4RED_FLAGS
    Cardiogenic shock SCAI C-E (the dominant clinical problem); mechanical complications; massive ischemic burden requiring MCS bridge; MCS team activation (Impella CP per DanGer Shock; VA-ECMO if biventricular failure)
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: shock staging + MCS plan documented
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + lactate + CBC + CXR + bedside echo (LV/RV function, mechanical complications, valvular)
    inputs: ecg, troponin, creatinine, lactate, echo_post_revasc
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Heart Team (immediate — interventional + cardiac surgeon + intensivist) for CABG-vs-PCI decision; SYNTAX score guides choice; DK-CRUSH for LMCA bifurcation if PCI chosen; CABG often preferred for distal LMCA + 3VD + DM + low SYNTAX
    inputs: cor_angio_with_syntax
    advance: revasc strategy chosen + delivered
  7. 7TREATMENT
    Standard ACS regimen (ASA + ticagrelor + UFH + statin) per cardio.stemi.core.v1; HOLD ticagrelor load if CABG decided pre-load (use cangrelor bridge or no load); MCS (Impella CP or VA-ECMO) for SCAI C+ per DanGer Shock; defer BB until shock resolves
    inputs: sbp, lactate, creatinine
    actions: protocol.stemi
    advance: revasc + MCS + bundle initiated
  8. 8DISPOSITION
    CICU mandatory; cardiac surgical ICU if CABG; long ICU stay typical given infarct size + MCS dwell time
    advance: ICU bed assigned + MCS plan documented
  9. 9MONITORING
    CICU/SICU telemetry + arterial line + PA catheter consideration; MCS weaning protocol; serial echo for LV recovery; vigilance for mechanical complications
    inputs: echo_post_revasc
    actions: panel.cardiac
    advance: MCS weaned or transition to durable strategy + LV recovery trajectory documented
  10. 10FOLLOWUP
    Cardiology + cardiac surgery follow-up; echo at 30-90 d for LVEF + ICD eligibility (MADIT-II); cardiac rehab; advanced HF eval if EF <30 not recovering
    advance: cardiac rehab booked + ICD pathway documented