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cardio.stemi.core.v1PRODUCTION
cardio.stemi.core.v1

STEMI / OMI (acute coronary syndrome)

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

STEMI = time-critical reperfusion per ACC/AHA 2025 Class I; OMI paradigm — treat occluded artery on ECG even without classical ST criteria (Meyers et al 2019)

Inputs
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Advance rule
Set
Advance when

STEMI / OMI / fibrinolysis-eligible diagnosis confirmed

Patient inputs (13)

Bradyarrhythmia in inferior MI; β-blocker timing per REDUCE-AMI 2024 + CAPRICORN

Contrast nephropathy risk + DOAC + enoxaparin dosing per EXTRACT-TIMI 25 2006

Reperfusion arrhythmia prevention (K + Mg) per ACC/AHA 2025 Class I

Diagnostic per ACC/AHA 2025 Class I; localizes infarct territory (anterior, inferior, RV, posterior, LMCA, LBBB-equiv)

4th Universal Definition of MI 2018; serial trending per ESC 2023

Cardiogenic shock screen per SCAI staging; nitrate contraindication if RV infarct (ACC/AHA 2025 Class III)

STREAM-2 half-dose TNK in elderly ≥75 yo + reperfusion strategy (ACC/AHA 2025)

Pre-reperfusion repletion per ACC/AHA 2025

Aspirin / contrast / antiplatelet allergies per ACC/AHA 2025 safety check

Cocaine-related ACS — benzo first; AVOID β-blocker monotherapy acute per ACC/AHA 2025 Class III

Cardiogenic shock SCAI staging (Baran et al 2019)

DAPT bleed risk (HAS-BLED) + fibrinolysis contraindication per ACC/AHA 2025 Class III

Fibrinolysis absolute / relative contraindication per ACC/AHA 2025 Table 6

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningcardiogenic_shock_complicating_STEMI
    STEMI + SBP <90 + lactate ≥2 + hypoperfusion (cool extremities, AKI, AMS) per SCAI staging (Baran et al 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication
    New systolic murmur + decompensation 3–7 d post-MI (acute MR from papillary rupture, VSR, free-wall rupture) per ACC/AHA 2025 Class I
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_MI_VT_VF
    Sustained VT or VF after STEMI per ACC/AHA 2025
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredoor_to_balloon_at_risk
    On-site PCI cannot be delivered within 90 min OR FMC-to-device cannot be delivered within 120 min per ACC/AHA 2025 Class I
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefibrinolysis_failed
    No ST resolution ≥50% at 60–90 min post-lytic OR persistent pain / hemodynamic instability per REACT 2005
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereRV_infarct_pattern
    Inferior STEMI + RV infarct on V4R + hypotension per ACC/AHA 2025
    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

STEMI acute — reperfusion + adjunctive antiplatelet/anticoagulant/anti-ischemic per ACC/AHA 2025
axis: stemi_acute_reperfusionstep 1 - Step 1 — Door (immediate ED bundle per ACC/AHA 2025 Class I, irrespective of PCI vs lytic)
Selected step "Step 1 — Door (immediate ED bundle per ACC/AHA 2025 Class I, irrespective of PCI vs lytic)" — STEMI/OMI confirmed on ECG with chest pain or anginal equivalent per ACC/AHA 2025
  • aspirin
    first line
    antiplatelet_COX1
    162–325 mg chewed • PO • once now then 81 mg daily
    triggers: STEMI_confirmed
    2025 ACC/AHA Class I — chewed non-enteric ASA at first medical contact
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load • PO • once now then 90 mg BID × 12 mo
    triggers: primary_PCI_planned
    PLATO 2009 — preferred over clopidogrel for primary PCI per ACC/AHA 2025 Class I; AVOID with prior ICH
    rxcui 1116632
  • prasugrel
    first line
    P2Y12_inhibitor
    60 mg load • PO • once now then 10 mg daily × 12 mo (5 mg if <60 kg or ≥75 yo)
    triggers: primary_PCI_planned, no_prior_stroke_or_TIA
    TRITON-TIMI 38 2007 — preferred in PCI-eligible without stroke history per ACC/AHA 2025 Class I
    rxcui 613391
  • clopidogrel
    second line
    P2Y12_inhibitor
    600 mg load (PCI) or 300 mg (lytic) • PO • once now then 75 mg daily × 12 mo
    triggers: fibrinolysis_strategy, high_bleed_risk, ticagrelor_or_prasugrel_contraindicated
    CLARITY-TIMI 28 — default if ticagrelor/prasugrel contraindicated; standard with fibrinolysis per ACC/AHA 2025 Class I
    rxcui 32968
  • nitroglycerin
    add on
    organic_nitrate
    0.4 mg SL q5min × 3 → IV 5–10 µg/min titrated • SL/IV • PRN ischemic pain; continuous IV if HF/HTN
    triggers: ongoing_chest_pain, pulmonary_edema, HTN
    ACC/AHA 2025 Class III — AVOID if RV infarct, SBP <90, or PDE5 inhibitor in last 24–48 h
    rxcui 4917
  • morphine
    rescue
    opioid_analgesic
    2–4 mg IV • IV • q5–15 min PRN
    triggers: refractory_pain_despite_nitrate
    ACC/AHA 2025 Class IIb — reserve for ongoing pain; may slow P2Y12 absorption (CRUSADE registry)
    rxcui 7052

outpatient playbook — drug actions (7)

  1. 1. DAPT duration decision at 12 months
    rxcui 1191
    Continue ASA 81 mg daily lifelong; decide P2Y12 continuation: extended (PEGASUS-style ticagrelor 60 mg BID up to 36 mo if high ischemic / low bleed) OR de-escalate to P2Y12-monotherapy (HOST-EXAM 2021) OR ASA-only (SMART-CHOICE 2019) • PO • daily / BID
    trigger: 12 mo post-PCI/lytic; bleed risk vs ischemic risk re-assessment per ACC/AHA 2025
    PEGASUS 2015 (PMID 25773268) for extended ticagrelor; HOST-EXAM 2021 (PMID 34010616) for clopidogrel monotherapy superior to ASA; SMART-CHOICE 2019 (PMID 31237645) for de-escalation
  2. 2. lifelong high-intensity statin
    rxcui 83367
    Atorvastatin 80 mg or rosuvastatin 40 mg; add ezetimibe + PCSK9i as needed for LDL <55 • PO • daily
    trigger: Lifelong post-MI per ACC/AHA 2025 Class I
    ASCVD secondary prevention — IMPROVE-IT (PMID 26039521) + FOURIER (PMID 28304224) — keep LDL <55
  3. 3. BB long-term decision
    rxcui 6918
    Metoprolol succinate 25–200 mg daily — continue if EF <40%; consider deprescribing at 12 mo if preserved EF + asymptomatic per REDUCE-AMI 2024 • PO • daily
    trigger: Annual review at 12 mo and beyond
    REDUCE-AMI 2024 (PMID 38587241) — neutral in preserved EF over 3.5 yr (HR 0.96); CAPRICORN (PMID 11356434) sustained benefit if EF<40%
  4. 4. ACEi / ARNI lifelong if EF <40% or HTN/DM
    rxcui 29046
    Lisinopril 5–40 mg daily; consider switch to sac/val if HFrEF emerges • PO • daily
    trigger: EF <40% lifelong; HTN/DM/CKD long-term per ACC/AHA 2025 Class I
    GISSI-3 (PMID 7910229) sustained mortality benefit; PARADISE-MI (PMID 34758252) — sac/val is alternative not superior in post-MI
  5. 5. MRA if HFrEF develops
    rxcui 298869
    Eplerenone 25–50 mg daily or spironolactone 12.5–25 mg • PO • daily
    trigger: EF <40% + HF or DM per EPHESUS 2003
    EPHESUS (PMID 12668699) — sustained mortality benefit at 16 mo; monitor K and Cr
  6. 6. SGLT2i lifelong if EF <40% / DM / CKD
    rxcui 1488564
    Dapagliflozin 10 mg or empagliflozin 10 mg daily • PO • daily
    trigger: HFrEF / DM / CKD long-term per ACC/AHA 2025
    DAPA-MI 2024 (PMID 38320489) + DAPA-HF (PMID 31535829) + DELIVER (PMID 36027570) sustained benefit
  7. 7. PPI continuation while on DAPT
    rxcui 40790
    Pantoprazole 40 mg daily • PO • daily
    trigger: While DAPT continues + bleed-risk factor
    COGENT 2010 (PMID 20925534) — discontinue when single antiplatelet only

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Ischemic chest pain / anginal equivalent (ACC/AHA 2025 Class I); ECG STEMI / OMI / Sgarbossa+ / de Winter / Wellens (ESC 2023; Sgarbossa NEJM 1996; de Winter NEJM 2008); Rising troponin in ischemic context (4th Universal Definition of MI 2018).

Objective

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

Assessment

**STEMI / OMI (acute coronary syndrome)** (cardio.stemi.core.v1).
Scope: STEMI = time-critical reperfusion per ACC/AHA 2025 Class I; OMI paradigm — treat occluded artery on ECG even without classical ST criteria (Meyers et al 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **STEMI acute — reperfusion + adjunctive antiplatelet/anticoagulant/anti-ischemic per ACC/AHA 2025** — step "Step 1 — Door (immediate ED bundle per ACC/AHA 2025 Class I, irrespective of PCI vs lytic)".
1. aspirin 162–325 mg chewed PO once now then 81 mg daily (antiplatelet_COX1, first line) — 2025 ACC/AHA Class I — chewed non-enteric ASA at first medical contact
2. ticagrelor 180 mg load PO once now then 90 mg BID × 12 mo (P2Y12_inhibitor, first line) — PLATO 2009 — preferred over clopidogrel for primary PCI per ACC/AHA 2025 Class I; AVOID with prior ICH
3. prasugrel 60 mg load PO once now then 10 mg daily × 12 mo (5 mg if <60 kg or ≥75 yo) (P2Y12_inhibitor, first line) — TRITON-TIMI 38 2007 — preferred in PCI-eligible without stroke history per ACC/AHA 2025 Class I
4. clopidogrel 600 mg load (PCI) or 300 mg (lytic) PO once now then 75 mg daily × 12 mo (P2Y12_inhibitor, second line) — CLARITY-TIMI 28 — default if ticagrelor/prasugrel contraindicated; standard with fibrinolysis per ACC/AHA 2025 Class I
5. nitroglycerin 0.4 mg SL q5min × 3 → IV 5–10 µg/min titrated SL/IV PRN ischemic pain; continuous IV if HF/HTN (organic_nitrate, add on) — ACC/AHA 2025 Class III — AVOID if RV infarct, SBP <90, or PDE5 inhibitor in last 24–48 h
6. morphine 2–4 mg IV IV q5–15 min PRN (opioid_analgesic, rescue) — ACC/AHA 2025 Class IIb — reserve for ongoing pain; may slow P2Y12 absorption (CRUSADE registry)

Setting playbook (outpatient) — Long-term post-MI follow-up at 1–3 month + 6 month + annual cadence — sustain the 6-pillar secondary prevention bundle, manage comorbid HFrEF if it emerges, complete the COMPLETE-style staged revascularisation if planned, decide DAPT duration at 12 mo per HOST-EXAM 2021 / SMART-CHOICE 2019 / PEGASUS 2015, and bridge to chronic CAD / chronic HF engines
7. DAPT duration decision at 12 months Continue ASA 81 mg daily lifelong; decide P2Y12 continuation: extended (PEGASUS-style ticagrelor 60 mg BID up to 36 mo if high ischemic / low bleed) OR de-escalate to P2Y12-monotherapy (HOST-EXAM 2021) OR ASA-only (SMART-CHOICE 2019) PO daily / BID — 12 mo post-PCI/lytic; bleed risk vs ischemic risk re-assessment per ACC/AHA 2025 (PEGASUS 2015 (PMID 25773268) for extended ticagrelor; HOST-EXAM 2021 (PMID 34010616) for clopidogrel monotherapy superior to ASA; SMART-CHOICE 2019 (PMID 31237645) for de-escalation)
8. lifelong high-intensity statin Atorvastatin 80 mg or rosuvastatin 40 mg; add ezetimibe + PCSK9i as needed for LDL <55 PO daily — Lifelong post-MI per ACC/AHA 2025 Class I (ASCVD secondary prevention — IMPROVE-IT (PMID 26039521) + FOURIER (PMID 28304224) — keep LDL <55)
9. BB long-term decision Metoprolol succinate 25–200 mg daily — continue if EF <40%; consider deprescribing at 12 mo if preserved EF + asymptomatic per REDUCE-AMI 2024 PO daily — Annual review at 12 mo and beyond (REDUCE-AMI 2024 (PMID 38587241) — neutral in preserved EF over 3.5 yr (HR 0.96); CAPRICORN (PMID 11356434) sustained benefit if EF<40%)
10. ACEi / ARNI lifelong if EF <40% or HTN/DM Lisinopril 5–40 mg daily; consider switch to sac/val if HFrEF emerges PO daily — EF <40% lifelong; HTN/DM/CKD long-term per ACC/AHA 2025 Class I (GISSI-3 (PMID 7910229) sustained mortality benefit; PARADISE-MI (PMID 34758252) — sac/val is alternative not superior in post-MI)
11. MRA if HFrEF develops Eplerenone 25–50 mg daily or spironolactone 12.5–25 mg PO daily — EF <40% + HF or DM per EPHESUS 2003 (EPHESUS (PMID 12668699) — sustained mortality benefit at 16 mo; monitor K and Cr)
12. SGLT2i lifelong if EF <40% / DM / CKD Dapagliflozin 10 mg or empagliflozin 10 mg daily PO daily — HFrEF / DM / CKD long-term per ACC/AHA 2025 (DAPA-MI 2024 (PMID 38320489) + DAPA-HF (PMID 31535829) + DELIVER (PMID 36027570) sustained benefit)
13. PPI continuation while on DAPT Pantoprazole 40 mg daily PO daily — While DAPT continues + bleed-risk factor (COGENT 2010 (PMID 20925534) — discontinue when single antiplatelet only)

Non-pharmacologic actions:
- Annual influenza + pneumococcal + COVID + RSV vaccines (ACC/AHA 2025 Class I)
- Continue Mediterranean / DASH-style diet counselling at every visit (ACC/AHA 2025 Class I)
- Maintain ≥150 min/wk moderate aerobic + 2 strength sessions per ACC/AHA 2025 Class I
- Smoking cessation continued reinforcement (ACC/AHA 2025 Class I)
- Sleep apnea management if STOP-BANG positive
- Driving + return-to-work optimisation per cardiac rehab
- Sexual activity counselling — generally safe after rehab if asymptomatic per ACC/AHA 2025
- Annual depression screen (PHQ-9) per ACC/AHA 2025

AVOID / contraindication checks:
- Fibrinolysis_absolute_ci_check (ACC/AHA 2025 Table 6)
- Nitrate_avoid_RV_infarct_or_PDE5 (ACC/AHA 2025 Class III)
- Beta_blocker_avoid_decompensated_HF_or_shock (ACC/AHA 2025 Class III)
- ACEi_avoid_hypotension_or_AKI (ACC/AHA 2025 Class III)
- Ticagrelor_avoid_prior_ICH (PLATO 2009 exclusion criteria)
- Prasugrel_avoid_prior_stroke_TIA (TRITON TIMI 38 2007 contraindication)
- Morphine_caution_slows_P2Y12 (ACC/AHA 2025 Class IIb)

Monitoring

Regimen monitoring:
- ECG q15min first hour then q4h first 24h (ACC/AHA 2025 Class I)
- serial troponin q3-6h (4th Universal Definition of MI 2018)
- BMP q24h during admission (ACC/AHA 2025)
- lipid panel pre-discharge and 4-12wk post-discharge (ACC/AHA 2025 Class I)
- echo pre-discharge and at 40-90d for ICD eligibility (ACC/AHA 2025 Class I)
- reperfusion ST resolution at 60-90min post-lytic (REACT 2005)

Setting (outpatient) monitoring:
- Clinic visit at 1–3 mo (transition), then 6 mo, then annually (ACC/AHA 2025)
- Annual lipid panel (ACC/AHA 2025 Class I); 4-12 wk + 6 mo if titrating PCSK9i
- BMP + Mg every 6 mo if on RAASi/MRA
- A1c annually if DM
- KCCQ-12 / NYHA every visit if HFrEF
- Repeat echo annually if HFrEF; otherwise only on symptom change per ACC/AHA 2025 Class IIa

Monitoring phase: Telemetry per ACC/AHA 2025; serial troponin / BMP; LV function reassessment 40–90 d post-MI for ICD eligibility (ACC/AHA Class I)

Disposition

Current setting: outpatient — Long-term post-MI follow-up at 1–3 month + 6 month + annual cadence — sustain the 6-pillar secondary prevention bundle, manage comorbid HFrEF if it emerges, complete the COMPLETE-style staged revascularisation if planned, decide DAPT duration at 12 mo per HOST-EXAM 2021 / SMART-CHOICE 2019 / PEGASUS 2015, and bridge to chronic CAD / chronic HF engines

Disposition criteria:
- Stable on max-tolerated 6-pillar bundle + completed cardiac rehab + LDL <55 + no symptom recurrence ≥1 yr → ongoing chronic CAD management; bridge to chronic_coronary_syndrome.outpatient (chronic CAD engine)
- HFrEF emergence (EF <40% sustained) → handoff to cardio.hf.core.v1 chronic HF engine for 4-pillar GDMT
- Recurrent ischemia / new revascularisation needed → re-enter STEMI/NSTE-ACS engine if acute

Escalation triggers (move to higher acuity):
- Recurrent angina / new positive stress test → repeat angiography per ACC/AHA 2025 Class I
- New decompensated HF → escalate to cardio.acute-hf.core.v1
- New AF → CHA2DS2-VASc + anticoagulation decision; rate vs rhythm per ACC/AHA 2023 AF guideline
- Major bleed on antithrombotic → hold + multidisciplinary review
- PHQ-9 ≥10 → mental health referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] STEMI + SBP <90 + lactate ≥2 + hypoperfusion (cool extremities, AKI, AMS) per SCAI staging (Baran et al 2019)
- [LIFE_THREATENING] New systolic murmur + decompensation 3–7 d post-MI (acute MR from papillary rupture, VSR, free-wall rupture) per ACC/AHA 2025 Class I
- [LIFE_THREATENING] Sustained VT or VF after STEMI per ACC/AHA 2025

Citations

- 2025 ACC/AHA/ACEP/NAEMSP/SCAI ACS Guideline + 2023 ESC ACS Guidelines [PMID:40014670](https://pubmed.ncbi.nlm.nih.gov/40014670/)
- Cited evidence (PMID 37622654) [PMID:37622654](https://pubmed.ncbi.nlm.nih.gov/37622654/)
- Cited evidence (PMID 34709879) [PMID:34709879](https://pubmed.ncbi.nlm.nih.gov/34709879/)
- Cited evidence (PMID 30153967) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)
- Cited evidence (PMID 35115207) [PMID:35115207](https://pubmed.ncbi.nlm.nih.gov/35115207/)

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