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cardio.stemi.anterior.v1PRODUCTION
cardio.stemi.anterior.v1

Anterior wall STEMI (LAD culprit)

cardiologyacuteadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

Anterior STEMI = LAD culprit; large-territory infarct; high LV failure + thrombus + ICD-eligibility risk; route immediately to cardio.stemi.core.v1 for the reperfusion arc

Inputs
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Advance rule
Set
Advance when

anterior STEMI confirmed on ECG

Patient inputs (7)

Older anterior MI patients higher mortality + LV thrombus risk

Contrast nephropathy risk + dosing; eGFR for DOAC after PCI

V1–V6 ST↑ defines anterior wall; localizes proximal-LAD vs distal-LAD per leads involved (V1-V2 → septal/proximal LAD; V3-V4 → apical; V5-V6 → lateral extension)

Peak troponin proportional to infarct size; anterior MIs typically have higher peaks → larger infarct → worse outcomes (4th UDMI 2018)

LVEF + anterior wall motion + LV thrombus screen — repeat at 5-7 d for thrombus development (peaks day 3-7 post-anterior-MI)

Hypotension + anterior MI → cardiogenic shock high probability (SCAI 2022)

LAD culprit confirmation + lesion location (proximal vs distal) drives prognosis + complete revasc decision (COMPLETE PMID 31475795)

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

Severity triggers (5)

5 need judgement
  • informationallife_threateninganterior_stemi_with_cardiogenic_shock
    Anterior STEMI + SBP <90 + lactate ≥2 — high probability given LAD territory size (SCAI 2022 C+)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_septal_rupture
    New harsh holosystolic murmur post-anterior-MI + hemodynamic deterioration → VSR
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_vt_vf_in_first_48h
    Recurrent VT/VF in first 48h post-anterior-MI despite reperfusion
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelv_thrombus_on_post_anterior_mi_echo
    LV thrombus on echo at 5-7d post-anterior-MI (peak formation period)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewcd_bridge_failure_or_non_adherence
    WCD therapy delivered OR adherence <90% during 40-90d ICD eligibility window
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Anterior STEMI complication phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen
axis: anterior_stemi_complication_phenotype
Selected axis "Anterior STEMI complication phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed • PO • load + 81 mg daily
    triggers: stemi_post_rosc
    ACC/AHA 2025 ACS Class I; same as parent
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo default DAPT
    triggers: stemi_pci_planned
    PLATO PMID 19717846; same as parent
    rxcui 1116632
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR target 2-3 • PO • daily
    triggers: lv_thrombus_on_echo, apical_akinesia_with_severe_lv_dysfunction
    Standard 3-mo warfarin if LV thrombus per AHA 2022 Class IIa; consider DOAC alternative (apixaban) for compliance per COMMANDER-HF (PMID 30277645) — though direct LV-thrombus DOAC RCT data sparse
    rxcui 11289
  • apixaban
    comorbidity specific
    doac_factor_xa_direct
    5 mg BID (or 2.5 mg BID per dose-reduction criteria) • PO • BID × 3 mo for LV thrombus
    triggers: lv_thrombus_on_echo, warfarin_intolerant_or_contraindicated
    Off-label-but-rational DOAC alternative for LV thrombus; small RCTs (NoT-DAPT, Xarelto LV-thrombus) suggest non-inferiority to warfarin
    rxcui 1364430

outpatient playbook — drug actions (1)

  1. 1. continue secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT • PO • as scheduled
    trigger: post-anterior-MI
    AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ST elevation V1–V6 + reciprocal ST↓ inferior leads (anterior STEMI); Ischemic chest pain + anterior STEMI ECG → emergent cath within 90 min; New severe LV dysfunction on bedside echo + anterior wall akinesia.

Objective

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

Assessment

**Anterior wall STEMI (LAD culprit)** (cardio.stemi.anterior.v1).
Scope: Anterior STEMI = LAD culprit; large-territory infarct; high LV failure + thrombus + ICD-eligibility risk; route immediately to cardio.stemi.core.v1 for the reperfusion arc

No severity triggers fired against current inputs.

Plan

Regimen axis: **Anterior STEMI complication phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; same as parent
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo default DAPT (p2y12_inhibitor, first line) — PLATO PMID 19717846; same as parent
3. warfarin 5 mg daily; INR target 2-3 PO daily (vitamin_k_antagonist, comorbidity specific) — Standard 3-mo warfarin if LV thrombus per AHA 2022 Class IIa; consider DOAC alternative (apixaban) for compliance per COMMANDER-HF (PMID 30277645) — though direct LV-thrombus DOAC RCT data sparse
4. apixaban 5 mg BID (or 2.5 mg BID per dose-reduction criteria) PO BID × 3 mo for LV thrombus (doac_factor_xa_direct, comorbidity specific) — Off-label-but-rational DOAC alternative for LV thrombus; small RCTs (NoT-DAPT, Xarelto LV-thrombus) suggest non-inferiority to warfarin

Setting playbook (outpatient) — Long-term cardiology surveillance: 40-90d LVEF re-echo for ICD eligibility decision; cardiac rehab completion; secondary prevention bundle maintenance; mental health follow-up
5. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT PO as scheduled — post-anterior-MI (AHA 2025)

Non-pharmacologic actions:
- ICD/WCD adherence
- Cardiac rehab maintenance phase
- Driving restriction per state law if VF arrest

AVOID / contraindication checks:
- Warfarin_avoid_active_bleeding (AHA 2022)
- Apixaban_avoid_severe_renal_impairment_egfr_below_25 (drug label)
- Warfarin_TT_target_2 3_for_lv_thrombus (AHA 2022 Class IIa)

Monitoring

Regimen monitoring:
- echo at 5-7d for lv thrombus screen (peak thrombus formation)
- echo at 40d for lvef reassessment for icd eligibility (MADIT-II)
- INR q week during warfarin initiation (standard)

Setting (outpatient) monitoring:
- Quarterly + annual EF + lipid

Follow-up plan: Cardiology + EP follow-up; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); WCD bridge during interval if EF <35; cardiac rehab
- Close-out criterion: ICD/WCD pathway + cardiac rehab booked

Monitoring phase: Telemetry, daily exam for new murmur (papillary or VSR); echo at 5-7 d for thrombus; echo at 40 d for LVEF reassessment + ICD eligibility

Disposition

Current setting: outpatient — Long-term cardiology surveillance: 40-90d LVEF re-echo for ICD eligibility decision; cardiac rehab completion; secondary prevention bundle maintenance; mental health follow-up

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- EF declining despite GDMT → advanced HF eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Anterior STEMI + SBP <90 + lactate ≥2 — high probability given LAD territory size (SCAI 2022 C+)
- [LIFE_THREATENING] New harsh holosystolic murmur post-anterior-MI + hemodynamic deterioration → VSR
- [LIFE_THREATENING] Recurrent VT/VF in first 48h post-anterior-MI despite reperfusion

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + AHA 2022 HF (with 2023 Focused Update) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)
- Cited evidence (PMID 31475795) [PMID:31475795](https://pubmed.ncbi.nlm.nih.gov/31475795/)
- Cited evidence (PMID 11907286) [PMID:11907286](https://pubmed.ncbi.nlm.nih.gov/11907286/)

Last reconciled with current guidelines: 2026-05-14.
References