Patient handout

Recurrent STEMI in patient with prior MI history

PRODUCTION

1. Your condition

This handout is for recurrent stemi in patient with prior mi history. Your care team identified this based on: patient with documented prior mi presents with new stemi on ecg.

Other reasons your team may use this plan: new st elevation on ecg in patient with prior mi / prior pci — emergent cath with culprit-mechanism triage; recurrent acs in patient already on dapt or single apt — breakthrough ischemia → escalate antiplatelet + cath.

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 if not already on; continue 81 mg daily	PO	load + 81 mg daily indefinitely	AHA 2025 ACS Class I; lifelong post-MI
ticagrelor	180 mg load → 90 mg BID × 12 mo, then 60 mg BID extended-DAPT per PEGASUS-TIMI 54	PO	BID × 12 mo standard then BID extended	PLATO PMID 19717846; PEGASUS-TIMI 54 PMID 25773268 — long-term ticagrelor 60 mg BID reduces MACE in stable post-MI patients with high-risk features (recurrent MI is per-protocol high-risk)
heparin	70-100 U/kg IV bolus	IV	bolus → infusion per ACT	AHA 2025 Class I peri-PCI anticoagulation
atorvastatin	80 mg	PO	daily indefinitely	PROVE-IT PMID 15007110; intensified given recurrent ACS
evolocumab	140 mg SC q2w	SC	q2w	FOURIER PMID 28304224 — additive LDL reduction + MACE benefit; appropriate for recurrent ACS with persistent elevated LDL on max statin
carvedilol	3.125 mg BID titrate	PO	BID	CAPRICORN PMID 11356436 — post-MI BB benefit; cumulative dysfunction trajectory in recurrent MI
warfarin	5 mg daily; INR 2-3 × 3 mo	PO	daily	AHA 2022 Class IIa 3-mo AC for LV thrombus; recurrent MI cohort at higher cumulative risk

Plan: Recurrent STEMI phenotype — escalates antiplatelet + adds extended-DAPT (PEGASUS-TIMI 54) + ICD secondary prevention layer to parent cardio.stemi.core.v1 regimen

3. When to call your provider

Contact your care team if any of the following happen:

ICD therapy delivered → urgent EP
Recurrent ACS → repeat cath
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:

Angiography shows lesion at prior stent site; differentiate ISR (smooth tubular narrowing within stent, late presentation, neointimal hyperplasia) vs in-stent thrombosis (acute thrombotic pattern, often LST/VLST per ARC) — strategy diverges (DCB/DES for ISR vs aspiration thrombectomy + IVUS for stent apposition + GP IIb/IIIa for thrombosis)
Recurrent STEMI in patient confirmed adherent to therapeutic DAPT (ASA + clopidogrel/ticagrelor) — treatment failure; consider platelet function testing or CYP2C19 LOF for clopidogrel patients
Recurrent STEMI patient with cumulative LV dysfunction trajectory (EF declining over multiple events) + new LV thrombus on echo at 5-7 d
Recurrent STEMI complicated by VT/VF → secondary-prevention ICD per AVID (no 40-d wait); OR EF ≤30 at 40-90 d → primary-prevention per MADIT-II

5. Follow-up

Cardiology + EP follow-up; ICD secondary-prevention if VT/VF (no 40-d wait); heart pumping strength (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

6. Sources

Guideline: 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + AVID secondary prevention ICD framework + PEGASUS-TIMI 54 extended DAPT