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cardio.post-arrest.core.v1PRODUCTION
cardio.post-arrest.core.v1

Post-cardiac-arrest care (cardiology-driven, ischemic-OHCA pathway)

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

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Frame

Detailed

Cardiology-driven post-arrest pathway: ROSC after presumed cardiac etiology — confirm shockable rhythm OR ischemic ECG OR known CAD; if non-cardiac etiology, route to cc.post-arrest-care.core.v1 (AHA 2020)

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cardiac etiology confirmed or strongly suspected

Patient inputs (15)

Age + frailty drive prognostic discussion + ICD eligibility (AHA 2020; MADIT-II PMID 11907286)

Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020; CAHP / OHCA scores)

Shockable (VF/pVT) → cardiac etiology > 80% probability; emergent cath if STEMI (AHA 2020 Class I; COACT NEJM 2019; TOMAHAWK NEJM 2021)

CPR duration → ECPR eligibility (ARREST PMID 33197396 — selection: <60 min low-flow); neuro prognosis

AKI common post-arrest; contrast / drug dosing (AHA 2020)

Arrhythmogenic; correct to 4–4.5 mmol/L (AHA 2020 Class I)

STEMI → emergent cath within 90 min (AHA 2020 Class I; ESC 2023 ACS)

Cardiac etiology + STEMI/NSTEMI workup; serial trending (AHA 2020; 4th UDMI 2018)

Tissue hypoperfusion + clearance trajectory (SCAI 2022 CS staging Baran PMID 31104355)

MAP ≥65 target post-ROSC; vasopressor titration (AHA 2020 Class IIa)

TTM target 33–37.5 °C per TTM2 (Dankiewicz NEJM 2021 PMID 34133859) + HYPERION (Lascarrou NEJM 2019 PMID 31577396 for non-shockable)

Avoid hyperoxia: target SpO2 92–98% (AHA 2020 Class IIa)

STEMI → emergent (Class I); shockable non-STEMI → routine vs delayed per COACT/TOMAHAWK (AHA 2020 Class IIb)

Prior MI / EF / valvular / device → ICD vs WCD post-discharge (MADIT-II; DINAMIT PMID 15590950)

LV function / RV strain / valvular cause / tamponade — drives MCS decision (AHA 2020 Class I)

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningrecurrent_vf_pvt_post_rosc
    Recurrent VF/pVT episodes post-ROSC despite ACLS pharmacotherapy (AHA 2020 ACLS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningstemi_on_post_rosc_ecg
    ST elevation meeting STEMI criteria on first post-ROSC ECG (AHA 2020 Class I — emergent cath)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_vf_arrest_arrest_criteria
    Persistent VF/pVT despite ≥3 defib + amiodarone + epinephrine; meets ARREST criteria (age 18-75, witnessed, bystander CPR, low-flow <60 min)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiogenic_shock_post_rosc
    Post-ROSC SBP <90 + lactate ≥2 + cool extremities + AKI — SCAI 2022 stage C+
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremultimodal_poor_neuro_prognosis_72h
    At ≥72h post-rewarm, ≥2 of: bilateral absent N20 SSEP + status myoclonus on EEG + NSE >60 ng/mL + diffuse anoxic injury on MRI + GCS motor ≤2 off sedation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateshivering_during_ttm
    Bedside Shivering Assessment Scale (BSAS) ≥2 during TTM cooling phase
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehyperoxia_post_rosc
    PaO2 >300 OR SpO2 100% on FiO2 >50% sustained > 30 min post-ROSC
    Trigger could not be auto-evaluated — needs clinician judgement.

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TREATMENTrequiredDrives monitoring threshold
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Recommended regimen

Post-arrest cardiac-etiology phenotype ladder — drives TTM + reperfusion + MCS coordination (AHA 2020 + TTM2 + DanGer Shock + ARREST)
axis: post_arrest_etiology_phenotypestep 1 - Phenotype 1 — Shockable rhythm + STEMI on ECG (highest survival, time-critical reperfusion)
Selected step "Phenotype 1 — Shockable rhythm + STEMI on ECG (highest survival, time-critical reperfusion)" — Initial rhythm VF/pVT + ROSC + post-ROSC 12-lead ECG meets STEMI criteria (Sgarbossa+ if LBBB/paced); ~25% of OHCA
  • aspirin
    first line
    antiplatelet_cox1
    162–325 mg chewed (or PR if intubated) • PO/PR • load + 81 mg daily
    triggers: stemi_post_rosc, no_aspirin_allergy
    ACC/AHA 2025 ACS Class I; ISIS-2 (PMID 2899772)
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO/NG • BID
    triggers: stemi_pci_planned
    PLATO (Wallentin NEJM 2009 PMID 19717846); preferred over clopidogrel in invasive strategy
    rxcui 1116632
  • unfractionated heparin
    first line
    anticoagulant_indirect_xa
    70–100 U/kg IV bolus → infusion to ACT 250–300 • IV • bolus + continuous
    triggers: pci_planned, no_active_bleeding
    AHA 2025 ACS Class I; HORIZONS-AMI (PMID 18499566)
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO/NG • daily
    triggers: stemi_post_rosc, no_active_hepatitis
    PROVE-IT TIMI-22 (PMID 15007110); IMPROVE-IT (PMID 26039521)
    rxcui 83367
  • metoprolol succinate
    first line
    beta1_selective_blocker
    25 mg PO daily — defer if shock or AV block • PO/NG • daily; titrate
    triggers: lvef_below_40, no_cardiogenic_shock, no_high_grade_av_block
    CAPRICORN (PMID 11356434); REDUCE-AMI 2024 nuance for preserved-EF (PMID 38959490)
    rxcui 6918

outpatient playbook — drug actions (4)

  1. 1. antiplatelet maintenance
    rxcui 243670
    ASA 81 mg daily ± P2Y12 per DAPT duration • PO • daily
    trigger: post-ACS
    Indefinite ASA per AHA 2025 unless contraindication; DAPT 12 mo default with risk-tailored shortening per MASTER DAPT PMID 34449185
  2. 2. high-intensity statin maintenance
    rxcui 83367
    atorvastatin 80 mg daily; LDL goal <55 • PO • daily
    trigger: post-ACS
    IMPROVE-IT; FOURIER (PMID 28304224); add ezetimibe + PCSK9i if LDL not at goal
  3. 3. GDMT maintenance for HFrEF
    rxcui 1656339
    ARNI + BB + MRA + SGLT2i at max tolerated dose • PO • as scheduled
    trigger: HFrEF post-arrest
    ACC/AHA 2022 HF 4-pillar Class I
  4. 4. channelopathy maintenance
    rxcui 6918
    metoprolol 100-200 mg/day if LQT/CPVT • PO • daily
    trigger: channelopathy diagnosis
    HRS 2017 PMID 29097319

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after VF/pVT cardiac arrest (AHA 2020 §3; ARREST 2020); STEMI on first post-ROSC ECG (AHA 2020 Class I; ESC 2023 ACS); Comatose ROSC with suspected cardiac etiology — TTM candidate (TTM2 Dankiewicz NEJM 2021).

Objective

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

Assessment

**Post-cardiac-arrest care (cardiology-driven, ischemic-OHCA pathway)** (cardio.post-arrest.core.v1).
Phenotype framing: Etiology refinement: ACS / structural CAD / ischemic CMP / non-ischemic CMP / channelopathy (LQT, Brugada, CPVT) / WPW / commotio cordis / takotsubo (AHA 2020; HRS expert consensus 2017 PMID 29097319)
Scope: Cardiology-driven post-arrest pathway: ROSC after presumed cardiac etiology — confirm shockable rhythm OR ischemic ECG OR known CAD; if non-cardiac etiology, route to cc.post-arrest-care.core.v1 (AHA 2020)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Post-arrest cardiac-etiology phenotype ladder — drives TTM + reperfusion + MCS coordination (AHA 2020 + TTM2 + DanGer Shock + ARREST)** — step "Phenotype 1 — Shockable rhythm + STEMI on ECG (highest survival, time-critical reperfusion)".
1. aspirin 162–325 mg chewed (or PR if intubated) PO/PR load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; ISIS-2 (PMID 2899772)
2. ticagrelor 180 mg load → 90 mg BID PO/NG BID (p2y12_inhibitor, first line) — PLATO (Wallentin NEJM 2009 PMID 19717846); preferred over clopidogrel in invasive strategy
3. unfractionated heparin 70–100 U/kg IV bolus → infusion to ACT 250–300 IV bolus + continuous (anticoagulant_indirect_xa, first line) — AHA 2025 ACS Class I; HORIZONS-AMI (PMID 18499566)
4. atorvastatin 80 mg PO/NG daily (statin_high_intensity, first line) — PROVE-IT TIMI-22 (PMID 15007110); IMPROVE-IT (PMID 26039521)
5. metoprolol succinate 25 mg PO daily — defer if shock or AV block PO/NG daily; titrate (beta1_selective_blocker, first line) — CAPRICORN (PMID 11356434); REDUCE-AMI 2024 nuance for preserved-EF (PMID 38959490)

Setting playbook (outpatient) — Long-term cardiology surveillance — ICD/WCD management, GDMT maintenance, secondary prevention bundle, cardiac rehab completion, mental health follow-up, sudden-cardiac-death risk monitoring (AHA 2020; ACC/AHA 2022 HF; HRS 2017)
6. antiplatelet maintenance ASA 81 mg daily ± P2Y12 per DAPT duration PO daily — post-ACS (Indefinite ASA per AHA 2025 unless contraindication; DAPT 12 mo default with risk-tailored shortening per MASTER DAPT PMID 34449185)
7. high-intensity statin maintenance atorvastatin 80 mg daily; LDL goal <55 PO daily — post-ACS (IMPROVE-IT; FOURIER (PMID 28304224); add ezetimibe + PCSK9i if LDL not at goal)
8. GDMT maintenance for HFrEF ARNI + BB + MRA + SGLT2i at max tolerated dose PO as scheduled — HFrEF post-arrest (ACC/AHA 2022 HF 4-pillar Class I)
9. channelopathy maintenance metoprolol 100-200 mg/day if LQT/CPVT PO daily — channelopathy diagnosis (HRS 2017 PMID 29097319)

Non-pharmacologic actions:
- ICD/WCD adherence and battery monitoring
- Cardiac rehab completion (12-week program); maintenance phase thereafter (AHA 2020 Class I)
- Ongoing CPR/AED training for family (AHA 2020)
- Driving restriction post-arrest per state law + AHA 2020 (typically 6 mo if VF/VT-driven arrest before resumption)
- Sleep study if OSA suspected (AHA 2022 HF)

AVOID / contraindication checks:
- Beta_blocker_avoid_acute_cardiogenic_shock (AHA 2020)
- Nitroglycerin_avoid_rv_infarct (AHA 2025 ACS)
- Flecainide_avoid_structural_cad (CAST trial; HRS 2017)
- Hypothermia_avoid_pre_ROSC_cooling (ARCTIC; Bernard 2022)
- Hyperoxia_avoid_post_rosc (AHA 2020 Class IIa: target SpO2 92–98%)
- Hyperthermia_avoid_post_rewarm × 72h (TTM2; Sandroni ERC ESICM 2021)
- Hyperventilation_avoid_post_rosc (target PaCO2 35–45 — avoid <30 cerebral vasoconstriction; AHA 2020)

Monitoring

Regimen monitoring:
- continuous ecg telemetry (AHA 2020 Class I)
- arterial line + MAP q1min (AHA 2020 Class IIa during pressor titration)
- core temperature continuous via bladder or esophageal probe (TTM2 PMID 34133859)
- shivering assessment BSAS q1h (Sandroni ERC-ESICM 2021)
- lactate q2-4h until normalized (SCAI 2022 PMID 31104355)
- serial troponin q2-3h x 3 then q6h (4th UDMI 2018)
- BMP q6-12h + Mg + Phos + ionized Ca (AHA 2020)
- EEG continuous for 24-48h for status epilepticus detection (Sandroni 2021)
- NSE at 24h 48h 72h for neuroprognostication (ERC-ESICM 2021; PMID 33773827)
- SSEP N20 bilateral for neuroprognostication at 72h after rewarm (ERC-ESICM 2021)
- MRI brain at 2-7 days for diffuse anoxic injury pattern (ERC-ESICM 2021)

Setting (outpatient) monitoring:
- Quarterly BP + weight + symptom score (HF if applicable)
- Annual ECG ± Holter if structural disease
- Annual echo if HFrEF history (Class IIa)
- Annual lipid + HbA1c (Class I)

Follow-up plan: Cardiology + electrophysiology follow-up at 1-2 weeks; LVEF reassessment at 40-90 days for primary-prevention ICD eligibility (MADIT-II); WCD bridge if EF <35% during waiting period (VEST trial PMID 30280654); cardiac rehab (AHA 2020 Class I); sudden-cardiac-death prevention bundle
- Close-out criterion: cards + EP follow-up booked + WCD decision + family screening if channelopathy

Monitoring phase: Continuous telemetry + arterial line + central line + Foley; q1h UOP; lactate q2-4h; BMP q6-12h; serial troponin until peak; daily echo if cardiogenic shock; multimodal neuroprognostication ≥72h after rewarm (Sandroni ERC-ESICM 2021 PMID 33773827: bilateral absent N20 SSEP + status myoclonus + EEG burst-suppression + NSE > 60 + diffuse anoxic injury on MRI)

Disposition

Current setting: outpatient — Long-term cardiology surveillance — ICD/WCD management, GDMT maintenance, secondary prevention bundle, cardiac rehab completion, mental health follow-up, sudden-cardiac-death risk monitoring (AHA 2020; ACC/AHA 2022 HF; HRS 2017)

Disposition criteria:
- Long-term continuation in this engine; cross-link to cardio.hf.core.v1 for chronic HF management; cross-link to cardio.ascvd.chronic.v1 for secondary prevention bundle

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP eval; consider antiarrhythmic + ablation per VANISH (PMID 27149033)
- EF declining on serial echo despite GDMT → advanced HF eval
- New angina / abnormal stress → cath
- New depression / PTSD symptom → mental health referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Recurrent VF/pVT episodes post-ROSC despite ACLS pharmacotherapy (AHA 2020 ACLS)
- [LIFE_THREATENING] ST elevation meeting STEMI criteria on first post-ROSC ECG (AHA 2020 Class I — emergent cath)
- [LIFE_THREATENING] Persistent VF/pVT despite ≥3 defib + amiodarone + epinephrine; meets ARREST criteria (age 18-75, witnessed, bystander CPR, low-flow <60 min)

Citations

- 2020 AHA ACLS / Post-Cardiac-Arrest Care + 2021 ERC-ESICM Post-Resuscitation + 2025 ACC/AHA ACS + 2022 ACC/AHA HF (with 2023 Focused Update) [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 24237006) [PMID:24237006](https://pubmed.ncbi.nlm.nih.gov/24237006/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 31577396) [PMID:31577396](https://pubmed.ncbi.nlm.nih.gov/31577396/)
- Cited evidence (PMID 31291529) [PMID:31291529](https://pubmed.ncbi.nlm.nih.gov/31291529/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2020 AHA ACLS / Post-Cardiac-Arrest Care + 2021 ERC-ESICM Post-Resuscitation + 2025 ACC/AHA ACS + 2022 ACC/AHA HF (with 2023 Focused Update) — PMID:33081530
  • Cited evidence (PMID 24237006) — PMID:24237006
  • Cited evidence (PMID 34133859) — PMID:34133859
  • Cited evidence (PMID 31577396) — PMID:31577396
  • Cited evidence (PMID 31291529) — PMID:31291529