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cardio.stemi.radiation-induced.v1

Radiation-induced STEMI (post chest/mediastinal XRT)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.stemi.core.v1 — radiation-induced coronary artery disease + STEMI in cancer survivors with prior chest/mediastinal radiotherapy. Inherits reperfusion + antiplatelet + statin + BB regimen from parent via routing; specializes for ostial-lesion PCI procedural strategy (IVUS/OCT mandatory, intravascular lithotripsy often needed, radial access preferred), elevated CABG mortality in irradiated mediastinum, concomitant radiation valvulopathy/pericardial constriction surveillance, and aggressive secondary prevention given accelerated ASCVD trajectory. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (radiation-induced specifics documented inline). Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as Phase E rare-etiology variant.

Entry points (3)

  • history
    Prior mediastinal/chest XRT ≥5 years (Hodgkin lymphoma, breast, lung, esophageal cancer) → consider radiation-induced CAD as STEMI etiology
    prior_chest_radiotherapy_5yr_plus
  • imaging
    ST-elevation MI ECG in cancer survivor with prior chest XRT — likely ostial coronary disease
    ecg_stemi_in_cancer_survivor
  • symptom
    Atypical/typical angina in patient <55 with prior Hodgkin XRT — high pretest probability of accelerated ostial CAD
    angina_in_young_hodgkin_survivor

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Radiation-induced STEMI presents 1-2 decades earlier than de novo ASCVD; young age + chest-XRT history is the diagnostic signature
  • prior_chest_xrt_dose_field_yearrequired
    history • used at CONTEXT
    Dose >30 Gy + mantle/mediastinal field + interval ≥5 yr defines high-risk radiation-CAD substrate (Heidenreich PMID 17891999)
  • cancer_diagnosis_treatment_historyrequired
    history • used at CONTEXT
    Active malignancy alters AC/DAPT bleed risk + may preclude long-term DAPT; current oncology status determines bundle aggressiveness
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension in radiation-induced STEMI may also reflect concurrent constrictive/restrictive radiation pericardial injury, not pure cardiogenic shock
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Standard STEMI criteria; ostial LAD radiation-CAD often gives anterior STEMI pattern; check for conduction disease (radiation-related fibrosis)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Standard ACS biomarker; in radiation-induced microvascular disease may be modestly elevated even without obstructive CAD
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + DOAC dosing; cancer patients often have baseline AKI from chemo or contrast load
  • cor_angio_with_ivus_octrequired
    imaging • used at TREATMENT
    IVUS/OCT MANDATORY for ostial radiation-CAD assessment — coronary CTA underestimates ostial stenosis severity due to motion + calcium artefact (ESC cardio-onc 2022 PMID 36017575)
  • echo_pericardium_valve_screenrequired
    imaging • used at INITIAL_WORKUP
    Concomitant radiation valvulopathy (calcific AS, MR) + constrictive pericarditis screening — mandatory in radiation survivors

12-phase flow (10)

  1. 1FRAME
    Radiation-induced STEMI = chest XRT survivor presenting with ostial-pattern ACS; route to cardio.stemi.core.v1 reperfusion arc but flag ostial-disease workflow + IVUS-mandatory + multidisciplinary cardio-onc consult
    inputs: ecg, prior_chest_xrt_dose_field_year
    advance: STEMI confirmed + radiation history elicited
  2. 2ENTRY
    Cath lab within 90 min; bedside echo for LV + pericardial constriction screen (radiation pericardial disease may complicate hemodynamics)
    inputs: age
    advance: cath lab activated
  3. 3CONTEXT
    Radiation dose/field/interval; current oncology status (active disease vs survivorship); allergies; bleed risk; concurrent chemo (anthracycline cardiotoxicity overlap)
    inputs: sbp, creatinine, cancer_diagnosis_treatment_history
    advance: cardio-onc context complete
  4. 4RED_FLAGS
    Cardiogenic shock (radiation pericardial constriction may mimic/worsen); acute valvular dysfunction (radiation MR/AS rupture); secondary malignancy (radiation-induced sarcoma in field)
    inputs: sbp
    actions: cardiogenic_shock
    advance: shock + concurrent radiation injury screened
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + CBC + CXR; bedside echo with focus on pericardium (constriction), valves (radiation calcific AS/MR), LV function
    inputs: ecg, troponin, creatinine, echo_pericardium_valve_screen
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup + radiation-injury baseline documented
  6. 6BRANCHING_WORKUP
    Primary PCI of ostial lesion with IVUS/OCT guidance (radiation-CAD = calcified, fibrotic, ostial — IVUS critical for sizing + stent landing zones); CABG only if PCI not feasible AND surgical risk acceptable in irradiated chest
    inputs: cor_angio_with_ivus_oct
    advance: reperfusion strategy chosen with IVUS data
  7. 7TREATMENT
    Standard ACS regimen (ASA + ticagrelor + UFH + statin + BB) per cardio.stemi.core.v1; PCI strategy: prefer radial access (chest-wall lymphedema may impair femoral); IVUS-guided ostial stenting; high-pressure post-dilation; consider intravascular lithotripsy for calcified ostial disease; aggressive secondary prevention with high-intensity statin + ACEi/ARB + SGLT2i if HF risk
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: reperfusion + secondary-prevention bundle started
  8. 8DISPOSITION
    CICU post-PCI; cardio-onc multidisciplinary consult; surveillance plan for valvular/pericardial radiation disease
    advance: unit assigned + cardio-onc plan documented
  9. 9MONITORING
    Telemetry; daily exam for new murmur (radiation valvulopathy progression); echo at 24-48h to reassess pericardial physiology; renal function trending (cancer + contrast)
    inputs: echo_pericardium_valve_screen
    actions: panel.cardiac
    advance: cardio-onc surveillance plan active
  10. 10FOLLOWUP
    Cardiology + cardio-oncology dual follow-up; serial echo q12mo for radiation valvulopathy; high-intensity secondary prevention; smoking cessation paramount; consider repeat CTA at 5yr post-PCI
    advance: cardio-onc longitudinal plan booked