Patient handout

STEMI — SLE-associated coronary vasculitis (immune-complex inflammation + premature CAD)

PRODUCTION

1. Your condition

This handout is for stemi — sle-associated coronary vasculitis (immune-complex inflammation + premature cad). Your care team identified this based on: stemi in patient with established sle — premature cad vs vasculitis vs aps-thrombosis triage.

Other reasons your team may use this plan: stemi in young woman (<50) with autoimmune features (malar rash, arthritis, serositis, cytopenias) — de novo sle consideration; coronary cath in young sle patient showing diffuse disease, multivessel involvement, or vasculitic pattern (long stenoses, no discrete plaque) on ivus/oct; positive ana + anti-dsdna + low c3/c4 + active sle flare features in stemi patient — immune-complex coronary inflammation suspect.

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 load → 81 mg daily lifelong	PO	daily indefinitely	AHA 2025 ACS Class I + EULAR 2023 (PMID 36750244) — ASA in SLE arterial event; concurrent with warfarin if APS overlap predominant
ticagrelor	180 mg load → 90 mg BID	PO	BID × 12 mo standard DAPT, then reassess given vasculitis status	PLATO PMID 19717846; standard ACS DAPT applies; duration extension if persistent vasculitis activity
unfractionated_heparin	70-100 U/kg IV bolus + activated infusion	IV	bolus + infusion at PCI; transition to oral AC if APS overlap	AHA 2025 Class I for PCI; UFH preferred over LMWH in APS overlap (anti-Xa more reliable than aPTT if LA prolongs baseline)
atorvastatin	80 mg daily lifelong	PO	daily	PROVE-IT PMID 15007110; high-intensity statin lifelong post-MI; pleiotropic anti-inflammatory effect particularly relevant for SLE endothelial dysfunction
hydroxychloroquine	200-400 mg daily (≤5 mg/kg ideal weight)	PO	daily lifelong	EULAR 2023 (PMID 36750244) Class I — HCQ foundational for ALL SLE patients regardless of activity; cardiovascular benefit (Ruiz-Irastorza 2010 PMID 20132533) — reduces thrombosis + flares + lipid improvement; safe in pregnancy
methylprednisolone	1 g IV daily × 3-5 days	IV	pulse × 3-5 d	EULAR 2023 — pulse steroids for severe organ-threatening lupus including coronary vasculitis; bridge to oral prednisone + steroid-sparing agent
prednisone	1 mg/kg PO daily, taper over months	PO	daily with taper schedule	EULAR 2023 (PMID 36750244) — oral steroid taper after pulse; goal is steroid minimization with steroid-sparing agent
cyclophosphamide	500-1000 mg/m² IV monthly × 6 (or low-dose Euro-Lupus 500 mg q2w × 6)	IV	monthly × 6	EULAR 2023 — cyclophosphamide for severe organ-threatening SLE; coronary vasculitis qualifies; gonadotoxic — counseling required
mycophenolate_mofetil	1-3 g/d divided BID	PO	BID	ALMS PMID 19369404 — MMF non-inferior to cyclophosphamide for severe SLE; less gonadotoxic; preferred for women of reproductive age (but teratogenic — switch off before conception)
rituximab	1 g IV × 2 doses (days 0 + 14)	IV	2 doses	EULAR 2023 — rituximab off-label for refractory SLE; supported by observational series for organ-threatening disease
warfarin	5 mg daily; INR target 2.5-3.5 if APS overlap predominant	PO	daily lifelong if APS overlap	EULAR 2019 APS Class I; TRAPS PMID 30196097 — warfarin INR 2.5-3.5 lifelong if APS overlap is predominant driver (route to cardio.stemi.antiphospholipid-syndrome-related.v1)
carvedilol	3.125 mg BID titrate	PO	BID	CAPRICORN PMID 11356436 — post-MI BB benefit; carvedilol preferred for HFrEF GDMT
sacubitril-valsartan	24/26 mg BID titrate	PO	BID	PIONEER-HF PMID 30403955; ACC/AHA 2022 HF Class I if HFrEF persists post-MI

Plan: SLE coronary vasculitis + STEMI regimen — combines acute reperfusion with pulse immunosuppression and lifelong hydroxychloroquine + secondary prevention; APS overlap drives concurrent warfarin if predominant

3. When to call your provider

Contact your care team if any of the following happen:

New ACS or recurrent CAD on CTA → cardiology + rheumatology — assess vasculitis activity vs atherosclerosis
EF declining despite the four foundational heart-failure medications → advanced HF / transplant evaluation
Bleeding on triple therapy → reassess regimen
SLE flare → rheumatology — escalate immunosuppression
Pregnancy planned → switch teratogenic meds 3 mo prior + high-risk obstetrics + cardiology team

4. When to seek emergency care

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

IVUS/OCT confirms vessel-wall inflammation + active SLE serology (low C3/C4, elevated dsDNA) at index STEMI → pulse steroids + cyclophosphamide/MMF immediately(life-threatening)
Triple-positive APS antibodies + thrombus disproportionate to plaque on IVUS/OCT → APS-driven coronary thrombosis predominant; lifelong warfarin INR 2.5-3.5 vs immunosuppression-only(life-threatening)
Catastrophic APS — multi-organ thrombosis in <1 wk + STEMI + histopathologic small-vessel thrombosis → mortality 50% without aggressive triple therapy(life-threatening)
EF <35 + non-sustained VT on telemetry post-SLE-STEMI → SCD risk in 40-90 d window (often young patients with lifetime ICD implications)(life-threatening)
New-onset stroke / TIA / systemic embolism with vegetation on echo + STEMI patient → Libman-Sacks endocarditis + arterial thromboembolism
New fever / infiltrate / cytopenia during high-dose steroid + cyclophosphamide/MMF treatment — opportunistic infection (PJP, CMV, fungal, TB reactivation) high risk

5. Follow-up

Lifelong hydroxychloroquine; immunosuppression taper per rheumatology; aggressive secondary prevention (high-intensity statin, BP control to <130/80, no smoking); cardiology + rheumatology q3-6 mo; surveillance CTA at 1 yr; pregnancy + family planning counseling (HCQ safe in pregnancy, MMF/cyclophosphamide teratogenic — switch before conception)

6. Sources

Guideline: 2025 ACC/AHA ACS Guideline + EULAR 2023 SLE management recommendations (Fanouriakis ARD 2023 PMID 36750244) + ACR 2024 SLE management update + AHA cardiovascular risk in autoimmune disease scientific statement