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cardio.stemi.prior-mi-recurrent.v1

Recurrent STEMI in patient with prior MI history

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E clinical-context variant of cardio.stemi.core.v1 — narrowed to recurrent STEMI in patients with documented prior MI (with or without prior PCI/CABG). Triage axis: culprit mechanism (in-stent restenosis vs in-stent thrombosis vs new lesion at separate territory vs graft failure if prior CABG → handoff to post-CABG-MI engine). Key specializations: prior cath films + stent records mandatory; antiplatelet escalation (most patients already on DAPT — switch clopidogrel to ticagrelor for treatment-failure ACS); platelet function testing (VerifyNow PRU) or CYP2C19 LOF if breakthrough on therapeutic DAPT (TAILOR-PCI PMID 32840602); long-term ticagrelor 60 mg BID after standard 12 mo DAPT per PEGASUS-TIMI 54 (PMID 25773268); ICD secondary-prevention if VT/VF complicates per AVID (PMID 9411221) — no 40-d wait; LV thrombus risk higher (cumulative anterior wall dysfunction); intensified lipid with PCSK9 (FOURIER PMID 28304224) for LDL >70 on max statin. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (recurrent-MI-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 MI presents with new STEMI on ECG
    prior_mi_with_new_stemi
  • imaging
    New ST elevation on ECG in patient with prior MI / prior PCI — emergent cath with culprit-mechanism triage
    ecg_st_elevation_in_prior_mi_patient
  • symptom
    Recurrent ACS in patient already on DAPT or single APT — breakthrough ischemia → escalate antiplatelet + cath
    recurrent_acs_on_dapt

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Recurrent MI patients skew older with cumulative comorbidity burden
  • prior_mi_and_pci_historyrequired
    history • used at FRAME
    Detailed prior MI + PCI history: dates, vessels intervened, stent type/length, prior cath findings, current antiplatelet regimen — drives culprit-mechanism triage (ISR vs in-stent thrombosis vs new lesion)
  • current_antiplatelet_regimenrequired
    medication • used at CONTEXT
    Most prior-MI patients on DAPT or single APT; breakthrough ACS on therapeutic regimen → escalate (clopidogrel → ticagrelor, or add platelet function testing)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + recurrent STEMI → cardiogenic shock high probability (cumulative LV dysfunction; SCAI 2022)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Localize culprit territory; compare to prior baseline ECG (Q waves from prior MI may obscure current STEMI in same territory)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Confirms infarction; baseline may be elevated d/t prior MI scar burden
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + DOAC dosing
  • echo_post_pcirequired
    imaging • used at MONITORING
    LVEF + RV function + LV thrombus screen; compare to prior echos for cumulative dysfunction trajectory; LV thrombus risk higher (cumulative anterior wall dysfunction)
  • cor_angio_with_prior_film_reviewrequired
    imaging • used at TREATMENT
    Mandatory comparison to prior cath films; identify culprit (in-stent restenosis with neointimal hyperplasia vs in-stent thrombosis with thrombotic pattern vs new lesion at separate territory)

12-phase flow (10)

  1. 1FRAME
    Recurrent STEMI in prior-MI patient = treatment-failure ACS; triage culprit mechanism (ISR vs in-stent thrombosis vs new lesion vs graft failure if prior CABG); higher mortality than first MI per SWEDEHEART; route immediately to cardio.stemi.core.v1 for the reperfusion arc with recurrent-MI specialization
    inputs: prior_mi_and_pci_history
    advance: recurrent STEMI in prior-MI patient confirmed
  2. 2ENTRY
    Cath lab within 90 min; bedside echo for LVEF + RV strain; pull prior cath films + stent records
    inputs: age
    advance: cath lab activated
  3. 3CONTEXT
    Prior MI + PCI history (dates, vessels, stents), current antiplatelet regimen, allergies, bleed risk, prior platelet function testing or CYP2C19 status if available
    inputs: sbp, creatinine, current_antiplatelet_regimen
    advance: context complete + antiplatelet regimen review documented
  4. 4RED_FLAGS
    Cardiogenic shock (more common given cumulative LV dysfunction); life-threatening arrhythmia (recurrent VT/VF — secondary-prevention ICD indication per AVID); LV thrombus risk
    inputs: sbp
    actions: cardiogenic_shock
    advance: shock + arrhythmia screened
  5. 5INITIAL_WORKUP
    ECG (compare to prior baseline) + troponin + BMP + CBC + CXR; bedside echo (LV function trajectory, RV, valvular, thrombus); pull prior cath films + stent records + prior platelet function testing or CYP2C19 if available
    inputs: ecg, troponin, creatinine, echo_post_pci
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented + prior films pulled
  6. 6BRANCHING_WORKUP
    Diagnostic angiography with comparison to prior films; identify culprit mechanism: ISR (smooth tubular narrowing within stent, late presentation) vs in-stent thrombosis (acute thrombotic pattern, often late or very-late stent thrombosis) vs new lesion at separate territory; IVUS/OCT for ISR/thrombosis differentiation when ambiguous; consider DES vs DCB for ISR per ACC/AHA 2025
    inputs: cor_angio_with_prior_film_review
    advance: culprit mechanism identified + reperfusion strategy executed
  7. 7TREATMENT
    Standard ACS regimen via cardio.stemi.core.v1 (ASA + ticagrelor + UFH + statin + BB if EF↓); ESCALATE antiplatelet: if on clopidogrel → switch to ticagrelor (treatment-failure principle); platelet function testing if breakthrough on therapeutic DAPT (TAILOR-PCI PMID 32840602); consider CYP2C19 LOF genotype; intensified lipid (PCSK9 if LDL >70 on max statin); long-term ticagrelor 60 mg BID per PEGASUS-TIMI 54 after standard 12 mo DAPT; ICD secondary-prevention if VT/VF per AVID
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion delivered + escalated antiplatelet + ICD pathway documented
  8. 8DISPOSITION
    CICU post-PCI given higher complication probability + cumulative LV dysfunction
    advance: unit assigned + EP consult booked if VT/VF complicated
  9. 9MONITORING
    Telemetry; echo at 5-7 d for thrombus + LV function trajectory; daily exam for new murmur; CIN-AKI surveillance
    inputs: echo_post_pci
    actions: panel.cardiac, panel.renal
    advance: thrombus screen + arrhythmia surveillance documented
  10. 10FOLLOWUP
    Cardiology + EP follow-up; ICD secondary-prevention if VT/VF (no 40-d wait); LVEF re-echo at 40-90 d for primary-prevention ICD eligibility (MADIT-II EF ≤30); long-term ticagrelor 60 mg BID per PEGASUS-TIMI 54 after standard 12 mo DAPT; cardiac rehab; intensified secondary prevention
    advance: ICD pathway + extended-DAPT plan + cardiac rehab booked