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cardio.nstemi.post-pci-stent-thrombosis.v1PRODUCTION
cardio.nstemi.post-pci-stent-thrombosis.v1

Post-PCI stent thrombosis (NSTEMI presentation)

cardiologyacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Suspect stent thrombosis in any prior-PCI patient with new ACS; classify per ARC interval (acute / subacute / late / very-late) and DAPT-interruption history; route to parent cardio.nstemi.core.v1 for the universal regimen plus emergent re-cath workflow

Inputs
3
Actions
0
Advance rule
Set
Advance when

Stent-thrombosis suspicion documented

Patient inputs (12)

Emergent angiography confirms in-stent thrombus location and TIMI flow; gates IVUS/OCT use

IVUS/OCT identifies mechanism (under-expansion, mal-apposition, edge dissection, stent fracture, neoatherosclerosis) — drives PCI strategy and long-term plan

Age affects antiplatelet selection (prasugrel CONTRAINDICATED >75); influences IVUS/OCT use thresholds

Prasugrel CONTRAINDICATED <60 kg; weight-based heparin/IIb/IIIa

Stent type (DES vs BMS), date, location, lesion complexity drive ARC interval + likely mechanism (mal-apposition, neoatherosclerosis in late/very-late)

Current DAPT regimen + recent interruptions (surgery, dental, bleed) — most common cause of acute/subacute thrombosis per EAPCI 2014

Confirms NSTEMI/STEMI biomarker pattern per ESC 2023 0/1-h algorithm

Re-cath contrast nephropathy risk; eGFR for AC dosing

Hgb baseline before triple antithrombotic + IIb/IIIa; platelets for HIT/ITP rule-out (rare differential)

Serial ECG; in-stent thrombosis frequently presents as STEMI (TIMI 0 occlusion) → primary PCI triage

Hemodynamic instability common with large in-stent thrombus → MCS standby per DanGer Shock

CYP2C19 LOF (*2/*3) → clopidogrel non-response; TAILOR-PCI PMID 32840378 supports genotype-guided escalation

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningrecurrent_in_stent_thrombosis_during_admission
    Recurrent in-stent thrombosis during the same admission despite escalated DAPT and IVUS-guided optimisation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemodynamic_or_electrical_instability_with_in_stent_total_occlusion
    SBP <90 with hypoperfusion OR sustained VT/VF in patient with in-stent total occlusion (TIMI 0) → SCAI C+ shock + emergent reperfusion + MCS standby
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebreakthrough_stent_thrombosis_on_therapeutic_dapt
    Stent thrombosis confirmed on patient documented adherent to therapeutic DAPT (typically clopidogrel + aspirin) — gates immediate escalation to ticagrelor/prasugrel + CYP2C19 testing per TAILOR-PCI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecyp2c19_lof_discovered_post_event
    CYP2C19 LOF allele (*2 / *3) discovered on or after stent-thrombosis event in patient previously on clopidogrel — confirms etiology + drives lifelong escalation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateivus_confirms_under_expansion_or_mal_apposition
    IVUS or OCT during emergent re-cath confirms stent under-expansion, mal-apposition, edge dissection, or stent fracture as mechanism — gates immediate re-balloon optimisation + lifelong IVUS-guided requirement
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Stent-thrombosis escalated antithrombotic phenotype — escalates parent cardio.nstemi.core.v1 P2Y12 selection + adds selective IIb/IIIa + IVUS-guided PCI
axis: stent_thrombosis_escalated_antithrombotic_phenotype
Selected axis "Stent-thrombosis escalated antithrombotic phenotype — escalates parent cardio.nstemi.core.v1 P2Y12 selection + adds selective IIb/IIIa + IVUS-guided PCI" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg load → 81 mg • PO chewed • load once → 81 mg daily lifelong
    triggers: stent_thrombosis_confirmed_or_suspected
    Universal — ACC/AHA 2025 Class I; lifelong post-PCI
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID (consider 60 mg BID after 12 mo per PEGASUS for extended DAPT) • PO • BID × 12-30 mo per DAPT score / PEGASUS
    triggers: stent_thrombosis_breakthrough_on_clopidogrel, cyp2c19_lof_present_or_unknown
    Preferred escalation per TAILOR-PCI logic; PLATO PMID 19717846 net benefit; PEGASUS PMID 25773268 supports 60 mg BID 1-3 y post-MI extended phase
    rxcui 1116632
  • prasugrel
    first line
    P2Y12_inhibitor
    60 mg load → 10 mg daily (5 mg daily if wt <60 kg) • PO • daily × 12-30 mo per DAPT score
    triggers: stent_thrombosis_breakthrough_on_clopidogrel, pci_with_known_anatomy, no_prior_stroke_tia, age_le_75, weight_ge_60kg
    TRITON-TIMI 38 PMID 17982182 — superior to clopidogrel post-PCI; ISAR-REACT 5 PMID 31475799 — non-inferior to ticagrelor; CONTRAINDICATED prior stroke/TIA, age >75, wt <60
    rxcui 613391
  • cangrelor
    comorbidity specific
    P2Y12_inhibitor_iv_short_acting
    30 µg/kg IV bolus + 4 µg/kg/min infusion • IV • continuous during PCI then bridge to oral P2Y12
    triggers: oral_p2y12_not_reliable, shock_with_absent_gut_absorption, cabg_decision_pending
    CHAMPION-PHOENIX PMID 23394482 — IV P2Y12 useful when oral absorption unreliable or bridge decision pending; rapid onset/offset
    rxcui 1656052
  • unfractionated_heparin
    first line
    parenteral_anticoagulant
    60-70 U/kg IV bolus + infusion (titrate ACT 250-300 during PCI) • IV • continuous through PCI
    triggers: stent_thrombosis_pci_planned
    ACC/AHA 2025 Class I peri-PCI; reversible; preferred over enoxaparin in emergent re-cath setting
    rxcui 5224
  • eptifibatide
    comorbidity specific
    glycoprotein_iib_iiia_inhibitor
    180 µg/kg IV bolus × 2 (10 min apart) + 2 µg/kg/min infusion (renal dose-adjust) • IV • 12-18 h post-PCI
    triggers: high_thrombus_burden, no_reflow_phenomenon, recurrent_in_lab_thrombosis
    Selective use per ACC/AHA 2025 Class IIb; ESPRIT/EARLY-ACS data; bleed risk significant — reserve for high-burden thrombus or no-reflow
    rxcui 75635
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • once daily
    triggers: stent_thrombosis_confirmed
    PROVE-IT PMID 15007110; pleiotropic + plaque-stabilising effect particularly relevant in late/very-late stent thrombosis with neoatherosclerosis
    rxcui 83367

outpatient playbook — drug actions (3)

  1. 1. extended DAPT to 30 mo if DAPT score ≥2 + no major bleed
    aspirin 81 + ticagrelor 90 BID (or 60 mg BID per PEGASUS) OR prasugrel 10 • PO • daily/BID
    trigger: DAPT score ≥2; no major bleed
    DAPT trial PMID 25399658; PEGASUS PMID 25773268
  2. 2. maintain 5-pillar GDMT
    atorvastatin 80 + BB + ACEi + MRA + SGLT2i per indication • PO • as scheduled
    trigger: Post-MI maintenance
    ACC/AHA 2025 Class I
  3. 3. add PCSK9i if LDL >55 on max statin/ezetimibe
    evolocumab 140 mg q2 wk OR alirocumab 75 mg q2 wk • SC • q2 wk
    trigger: LDL >55 + very-high-risk
    FOURIER PMID 28304224

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Prior coronary stent + new ACS presentation — high pretest for stent thrombosis; ARC interval staging applies; Angiographic in-stent filling defect or TIMI 0 occlusion at prior-stent segment — definite stent thrombosis per ARC; Premature DAPT cessation (surgery, bleed, non-adherence) + new ACS — most common modifiable cause.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-PCI stent thrombosis (NSTEMI presentation)** (cardio.nstemi.post-pci-stent-thrombosis.v1).
Phenotype framing: In-stent thrombosis vs in-stent restenosis vs new lesion vs spontaneous coronary dissection vs vasospasm vs embolic — IVUS/OCT typically discriminates
Scope: Suspect stent thrombosis in any prior-PCI patient with new ACS; classify per ARC interval (acute / subacute / late / very-late) and DAPT-interruption history; route to parent cardio.nstemi.core.v1 for the universal regimen plus emergent re-cath workflow

No severity triggers fired against current inputs.

Plan

Regimen axis: **Stent-thrombosis escalated antithrombotic phenotype — escalates parent cardio.nstemi.core.v1 P2Y12 selection + adds selective IIb/IIIa + IVUS-guided PCI**.
1. aspirin 162-325 mg load → 81 mg PO chewed load once → 81 mg daily lifelong (antiplatelet_cox1, first line) — Universal — ACC/AHA 2025 Class I; lifelong post-PCI
2. ticagrelor 180 mg load → 90 mg BID (consider 60 mg BID after 12 mo per PEGASUS for extended DAPT) PO BID × 12-30 mo per DAPT score / PEGASUS (P2Y12_inhibitor, first line) — Preferred escalation per TAILOR-PCI logic; PLATO PMID 19717846 net benefit; PEGASUS PMID 25773268 supports 60 mg BID 1-3 y post-MI extended phase
3. prasugrel 60 mg load → 10 mg daily (5 mg daily if wt <60 kg) PO daily × 12-30 mo per DAPT score (P2Y12_inhibitor, first line) — TRITON-TIMI 38 PMID 17982182 — superior to clopidogrel post-PCI; ISAR-REACT 5 PMID 31475799 — non-inferior to ticagrelor; CONTRAINDICATED prior stroke/TIA, age >75, wt <60
4. cangrelor 30 µg/kg IV bolus + 4 µg/kg/min infusion IV continuous during PCI then bridge to oral P2Y12 (P2Y12_inhibitor_iv_short_acting, comorbidity specific) — CHAMPION-PHOENIX PMID 23394482 — IV P2Y12 useful when oral absorption unreliable or bridge decision pending; rapid onset/offset
5. unfractionated_heparin 60-70 U/kg IV bolus + infusion (titrate ACT 250-300 during PCI) IV continuous through PCI (parenteral_anticoagulant, first line) — ACC/AHA 2025 Class I peri-PCI; reversible; preferred over enoxaparin in emergent re-cath setting
6. eptifibatide 180 µg/kg IV bolus × 2 (10 min apart) + 2 µg/kg/min infusion (renal dose-adjust) IV 12-18 h post-PCI (glycoprotein_iib_iiia_inhibitor, comorbidity specific) — Selective use per ACC/AHA 2025 Class IIb; ESPRIT/EARLY-ACS data; bleed risk significant — reserve for high-burden thrombus or no-reflow
7. atorvastatin 80 mg PO once daily (statin_high_intensity, first line) — PROVE-IT PMID 15007110; pleiotropic + plaque-stabilising effect particularly relevant in late/very-late stent thrombosis with neoatherosclerosis

Setting playbook (outpatient) — Long-term — extended DAPT 30 mo per DAPT trial (score ≥2) OR ticagrelor 60 mg BID per PEGASUS post-12 mo; aggressive lipid + adherence; future PCI must be IVUS-guided; cross-link to chronic CAD engine
8. extended DAPT to 30 mo if DAPT score ≥2 + no major bleed aspirin 81 + ticagrelor 90 BID (or 60 mg BID per PEGASUS) OR prasugrel 10 PO daily/BID — DAPT score ≥2; no major bleed (DAPT trial PMID 25399658; PEGASUS PMID 25773268)
9. maintain 5-pillar GDMT atorvastatin 80 + BB + ACEi + MRA + SGLT2i per indication PO as scheduled — Post-MI maintenance (ACC/AHA 2025 Class I)
10. add PCSK9i if LDL >55 on max statin/ezetimibe evolocumab 140 mg q2 wk OR alirocumab 75 mg q2 wk SC q2 wk — LDL >55 + very-high-risk (FOURIER PMID 28304224)

Non-pharmacologic actions:
- Reinforce daily BP + symptom log
- Cardiac rehab maintenance phase
- Smoking cessation reinforcement
- Mediterranean / DASH diet counseling
- Adherence intervention re-emphasised every visit (recurrence is stent-thrombosis hallmark)
- Document IVUS-guided requirement for any future PCI

AVOID / contraindication checks:
- Prasugrel block if prior stroke TIA (TRITON TIMI 38)
- Prasugrel block if age above 75 or weight below 60kg (FDA boxed)
- Ticagrelor block if bradyarrhythmia without pacemaker (PLATO)
- Eptifibatide renal dose adjust if crcl below 50 (label)
- Eptifibatide block if active bleeding or recent stroke (label)
- Antithrombotic block if active bleeding (ACC/AHA 2025 Class III)

Monitoring

Regimen monitoring:
- ACT 250-300 during PCI (ACC/AHA 2025 Class I)
- CBC q4-6 h × 24 h on IIb/IIIa or triple antithrombotic (BARC 2011)
- Platelets baseline + q3 d (HIT screening; eptifibatide-induced thrombocytopenia)
- Creatinine baseline + q24 h post-contrast (KDIGO 2026)
- Bleeding signs (BARC) each shift through index admission
- CYP2C19 genotype if not previously done (TAILOR-PCI)

Setting (outpatient) monitoring:
- BMP at every visit
- Lipid panel every 6 mo — target LDL <55 very-high-risk; escalate to PCSK9i if not met
- Bleeding signs check at every visit through extended DAPT duration

Follow-up plan: Extended DAPT 30 mo (DAPT score ≥2) per Mauri NEJM 2014 OR ticagrelor 60 mg BID per PEGASUS PMID 25773268 if very-late thrombosis; CYP2C19 testing if not done (TAILOR-PCI); cardiac rehab; aggressive lipid + adherence reinforcement; consider IVUS-guided PCI for any future intervention
- Close-out criterion: Extended-DAPT plan + adherence + secondary-prevention bundle finalised

Monitoring phase: Continuous ECG/SpO2 for recurrent ischemia; CBC q4-6 h × 24 h on IIb/IIIa or triple antithrombotic per BARC 2011; ACT during PCI; bleeding signs each shift

Disposition

Current setting: outpatient — Long-term — extended DAPT 30 mo per DAPT trial (score ≥2) OR ticagrelor 60 mg BID per PEGASUS post-12 mo; aggressive lipid + adherence; future PCI must be IVUS-guided; cross-link to chronic CAD engine

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists; chronic CAD engine handoff with extended-DAPT plan + IVUS-required-for-future-PCI flag

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED + emergent re-cath
- BARC 2+ bleed → individualised reassessment with IC; consider TWILIGHT PMID 31475798 ticagrelor monotherapy if absolutely required
- NYHA worsening to III+ → expedite cardiology re-eval + echo

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Recurrent in-stent thrombosis during the same admission despite escalated DAPT and IVUS-guided optimisation
- [LIFE_THREATENING] SBP <90 with hypoperfusion OR sustained VT/VF in patient with in-stent total occlusion (TIMI 0) → SCAI C+ shock + emergent reperfusion + MCS standby
- [SEVERE] Stent thrombosis confirmed on patient documented adherent to therapeutic DAPT (typically clopidogrel + aspirin) — gates immediate escalation to ticagrelor/prasugrel + CYP2C19 testing per TAILOR-PCI

Citations

- 2025 ACC/AHA Guideline for ACS (Rao) — stent-thrombosis section; ESC 2023 ACS (Byrne, PMID 37622670); ARC stent thrombosis definitions (Cutlip, PMID 17470709) [PMID:17470709](https://pubmed.ncbi.nlm.nih.gov/17470709/)
- Cited evidence (PMID 32840378) [PMID:32840378](https://pubmed.ncbi.nlm.nih.gov/32840378/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 19717846) [PMID:19717846](https://pubmed.ncbi.nlm.nih.gov/19717846/)
- Cited evidence (PMID 17982182) [PMID:17982182](https://pubmed.ncbi.nlm.nih.gov/17982182/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2025 ACC/AHA Guideline for ACS (Rao) — stent-thrombosis section; ESC 2023 ACS (Byrne, PMID 37622670); ARC stent thrombosis definitions (Cutlip, PMID 17470709) — PMID:17470709
  • Cited evidence (PMID 32840378) — PMID:32840378
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 19717846) — PMID:19717846
  • Cited evidence (PMID 17982182) — PMID:17982182