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cardio.stemi.post-cabg-mi.v1

STEMI in prior-CABG patient (graft failure or native progression)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E clinical-context variant of cardio.stemi.core.v1 — narrowed to STEMI in patients with prior CABG. Two dominant mechanisms: (1) SVG failure (atherothrombosis, accelerated atherosclerosis at body or anastomosis — peak attrition 5-10 y post-CABG); (2) native vessel progression at non-grafted territory. LIMA failure rare (anatomic + biological protection per Loop NEJM 1986). Key specializations: mandatory full graft + native angiography (high contrast load → CIN-AKI surveillance); embolic protection device (FilterWire, SpiderFX) per SAFER PMID 11815441 for SVG-PCI; native PCI preferred over SVG body-PCI when feasible (better long-term patency per ISAR-CABG / SOS); IVUS/OCT for guide-wire confirmation in tortuous SVGs; lower MCS threshold given advanced CAD substrate (DanGer Shock PMID 38587234); heart-team consideration for redo CABG vs PCI in multivessel multi-graft-failure patients (SOS PMID 18316489); intensified secondary prevention with PCSK9 (FOURIER PMID 28304224) for LDL >70 on max statin. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (post-CABG-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute (Phase E wave 12).

Entry points (3)

  • history
    Patient with documented prior CABG presents with new STEMI on ECG
    prior_cabg_with_new_stemi
  • imaging
    New ST elevation on ECG in patient with prior CABG — emergent cath with graft + native angiography
    ecg_st_elevation_in_prior_cabg_patient
  • symptom
    Recurrent ischemic chest pain in prior-CABG patient + acute ECG change → emergent cath
    recurrent_angina_post_cabg_with_acute_change

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Post-CABG STEMI patients skew older (graft attrition peak 5-10 y); higher contrast/AC bleed risk
  • prior_cabg_anatomyrequired
    history • used at FRAME
    Prior CABG report: which vessels grafted (LIMA-LAD, SVG-RCA, SVG-OM, etc.), date of CABG, prior angiography findings, prior PCIs of grafts — drives culprit-vessel localization + intervention strategy
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + post-CABG STEMI → cardiogenic shock high probability (advanced CAD substrate; SCAI 2022)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Localizes culprit territory; may show pseudo-normalisation or atypical pattern given prior infarcts/grafts
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Confirms infarction; baseline may be elevated post-CABG patients with chronic ischemia
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk (multiple cath views needed for graft + native imaging); DOAC dosing; CIN-AKI prevention
  • echo_post_pcirequired
    imaging • used at MONITORING
    LVEF + RV function + valvular (post-CABG patients often have valve disease) + LV thrombus screen
  • cor_angio_with_graftsrequired
    imaging • used at TREATMENT
    Mandatory imaging of all grafts (LIMA, SVGs) AND native vessels; identify culprit (graft body stenosis, anastomotic stenosis, native progression at non-grafted territory)
  • current_antiplatelet_regimenrequired
    medication • used at CONTEXT
    Most prior-CABG patients on chronic ASA ± clopidogrel; need to escalate / load fully for ACS

12-phase flow (10)

  1. 1FRAME
    Post-CABG STEMI = either graft failure (SVG > LIMA) or native vessel progression at non-grafted territory; advanced CAD substrate → higher CS risk; route immediately to cardio.stemi.core.v1 for the reperfusion arc with post-CABG specialization layer
    inputs: prior_cabg_anatomy
    advance: STEMI in prior-CABG patient confirmed
  2. 2ENTRY
    Cath lab within 90 min; bedside echo for LVEF + RV strain + tamponade exclusion (prior sternotomy adhesions can mimic tamponade)
    inputs: age
    advance: cath lab activated
  3. 3CONTEXT
    Prior CABG operative report (vessels grafted, date, prior interventions), allergies, bleed risk, current antiplatelet regimen — most are on chronic ASA so need P2Y12 load
    inputs: sbp, creatinine, current_antiplatelet_regimen
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock (more common given advanced CAD substrate; lower MCS threshold per DanGer Shock); mechanical complications; tamponade in prior-sternotomy adhesion patient (atypical presentation)
    inputs: sbp
    actions: cardiogenic_shock
    advance: shock screened + MCS team alerted if SCAI B+
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + CBC + CXR (mediastinum widening — ascending aortic dissection mimicker post-sternotomy); bedside echo (LV function, RV, valvular, pericardial); pull prior CABG operative + prior cath films
    inputs: ecg, troponin, creatinine, echo_post_pci
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented + prior cath films pulled
  6. 6BRANCHING_WORKUP
    Diagnostic angiography of LIMA + all SVGs + native vessels (sequential, careful contrast use); identify culprit; if SVG culprit → embolic protection device (FilterWire, SpiderFX) per SAFER (PMID 11815441) before intervention; consider native PCI of distal target instead of SVG body-PCI when feasible (better long-term patency)
    inputs: cor_angio_with_grafts
    advance: reperfusion strategy executed
  7. 7TREATMENT
    Standard ACS regimen via cardio.stemi.core.v1 (ASA + ticagrelor + UFH + statin + BB if EF↓); ADD: embolic protection if SVG-PCI; IVUS/OCT for guide-wire confirmation in tortuous SVGs; redo CABG considered if multivessel native + multi-graft failure (heart-team decision); intensified secondary prevention (high-intensity statin + PCSK9 if LDL >70 + intensified anti-anginal + cardiac rehab)
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion delivered + intensified secondary prevention started
  8. 8DISPOSITION
    CICU post-PCI given higher complication / shock probability
    advance: unit assigned + heart-team consult booked if multivessel disease
  9. 9MONITORING
    Telemetry; echo at 5-7 d for thrombus + LV function; daily exam for new murmur (mechanical complications still occur); CIN-AKI surveillance d/t high contrast load
    inputs: echo_post_pci
    actions: panel.cardiac, panel.renal
    advance: thrombus screen + renal trajectory documented
  10. 10FOLLOWUP
    Cardiology + heart-team follow-up; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab; intensified secondary prevention; consider redo CABG evaluation if multivessel + recurrent symptoms
    advance: ICD/WCD pathway + cardiac rehab + heart-team f/u booked