Clinical Commander

Back to dossier
cardio.stemi.in-pregnancy-non-scad.v1PRODUCTION
cardio.stemi.in-pregnancy-non-scad.v1

STEMI in pregnancy — non-SCAD etiology (atherosclerotic / embolic / thrombotic)

cardiologyacuteadult
Hard-required inputs
0 / 8
Care setting:

Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

STEMI in pregnant or ≤6 wk postpartum patient — DISTINGUISH from SCAD (separate engine cardio.stemi.scad.v1) by cath findings; this engine covers atherosclerotic, embolic, thrombotic, vasospastic, takotsubo etiologies

Inputs
2
Actions
0
Advance rule
Set
Advance when

STEMI confirmed + pregnancy/postpartum status documented

Patient inputs (9)

Older maternal age (>35) + IVF era → atherosclerotic STEMI more common in pregnancy than historical

Drives radiation/medication risk profile; peri/postpartum window highest risk

Contrast nephropathy + medication dosing; pregnancy GFR ↑ 50% so absolute Cr lower than baseline

STEMI territory localization; identical to parent

Infarct sizing; troponin remains gold standard in pregnancy (NOT elevated by physiologic pregnancy)

LV function + RV strain (PE differential) + valvular + thrombus screen

Hemodynamic stratification + shock screen; pregnancy hemodynamics complex

Emergent cath with abdominal shielding (radiation 10-50× lower than CT-PE); essential for distinguishing SCAD vs plaque vs embolus vs vasospasm

Cocaine + sympathomimetics can cause STEMI in pregnancy; impacts treatment + delivery planning

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

Severity triggers (4)

4 need judgement
  • informationallife_threateningfibrinolysis_exposure_error_in_pregnancy
    Pregnant patient exposed to fibrinolysis (alteplase/tenecteplase) — ICH risk + placental abruption + fetal hemorrhage; should NEVER be given in pregnancy unless life-threatening PE/stroke with no alternative
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfetal_distress_requiring_delivery_during_acute_stemi
    Fetal distress on continuous monitoring during acute STEMI management (post-PCI or stabilization) requiring emergent delivery while maternal antiplatelet/anticoagulation active
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecocaine_intoxication_in_pregnancy_with_stemi
    Pregnant patient with cocaine on UDS + STEMI — placental abruption + fetal cocaine exposure + maternal vasospasm; AVOID pure beta-blocker (unopposed alpha worsens)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestatin_exposure_first_trimester
    Pregnant patient (especially first trimester) inadvertently exposed to statin — historically Class X concern for fetal cholesterol synthesis blockade + congenital anomalies
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
Loading…

Recommended regimen

Pregnancy-modified STEMI pharmacology — pregnancy-class-aware substitutions
axis: pregnancy_stemi_pharmacology_phenotype
Selected axis "Pregnancy-modified STEMI pharmacology — pregnancy-class-aware substitutions" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg load → 81 mg daily • PO • load + daily
    triggers: stemi_acute_pregnancy
    AHA 2025 Class I; low-dose ASA (≤150 mg) Class B in pregnancy + endorsed by ACOG for preeclampsia prevention; full STEMI dose acutely defensible per ESC 2018 pregnancy (PMID 30165544)
    rxcui 243670
  • clopidogrel
    first line
    p2y12_inhibitor
    600 mg load → 75 mg daily × 12 mo • PO • load + daily × 12 mo
    triggers: stemi_pci_pregnancy
    Pregnancy Class B; PREFERRED P2Y12 in pregnancy due to longer safety record vs ticagrelor (Class C, data limited); plan to interrupt 5-7 d before delivery if elective + consider bridging with bivalirudin
    rxcui 309362
  • heparin_unfractionated
    first line
    parenteral_anticoagulant
    70-100 U/kg IV bolus then infusion to aPTT 1.5-2.5×control • IV • bolus + infusion
    triggers: stemi_pci_pregnancy
    Does NOT cross placenta; reversible with protamine; PREFERRED over LMWH peri-cath/peri-delivery for reversibility
    rxcui 5224
  • metoprolol
    first line
    beta_blocker_b1_selective
    25-50 mg PO BID; titrate • PO • BID
    triggers: stemi_post_reperfusion_pregnancy, tachycardia_in_pregnancy
    Pregnancy Class C but safety record supports use; AVOID atenolol (Class D — FGR); labetalol Class C also acceptable; CAPRICORN extrapolation
    rxcui 6918
  • labetalol
    first line
    beta_blocker_alpha_beta
    100-200 mg PO BID; titrate • PO • BID
    triggers: hypertension_in_pregnancy, stemi_post_reperfusion_pregnancy
    Pregnancy preferred BB; ACOG 2019 first-line for HTN in pregnancy
    rxcui 6185
  • atorvastatin
    comorbidity specific
    statin
    HOLD in pregnancy unless absolute necessity (FDA Class X historical; 2021 FDA reconsidered for high-risk patients) • PO • HOLD
    triggers: post_delivery_or_homozygous_fh_pregnancy
    FDA 2021 statement: statin contraindication softened — case-by-case for high-risk patients; pravastatin lowest fetal exposure if needed; restart 6 wk postpartum (or only pravastatin if breastfeeding)
    rxcui 83367
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    AVOID throughout pregnancy • PO • AVOID
    triggers: lv_thrombus_or_aps_post_delivery_only
    Warfarin embryopathy 6-12 wk + fetal hemorrhage throughout; if AC indicated → LMWH (does not cross placenta); restart warfarin postpartum if needed
    rxcui 11289

outpatient playbook — drug actions (1)

  1. 1. continue full secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor or clopidogrel + statin + BB + ACEi/ARNI if EF<40 • PO • as scheduled
    trigger: post-STEMI
    AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ST elevation on ECG in pregnant patient (any trimester) or postpartum ≤6 wk; Ischemic chest pain in pregnant patient → urgent workup; differential includes SCAD, PE, aortic dissection, takotsubo; Chest pain in postpartum patient ≤6 wk (peak hypercoagulable + hemodynamic risk window).

Objective

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

Assessment

**STEMI in pregnancy — non-SCAD etiology (atherosclerotic / embolic / thrombotic)** (cardio.stemi.in-pregnancy-non-scad.v1).
Scope: STEMI in pregnant or ≤6 wk postpartum patient — DISTINGUISH from SCAD (separate engine cardio.stemi.scad.v1) by cath findings; this engine covers atherosclerotic, embolic, thrombotic, vasospastic, takotsubo etiologies

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pregnancy-modified STEMI pharmacology — pregnancy-class-aware substitutions**.
1. aspirin 162-325 mg load → 81 mg daily PO load + daily (antiplatelet_cox1, first line) — AHA 2025 Class I; low-dose ASA (≤150 mg) Class B in pregnancy + endorsed by ACOG for preeclampsia prevention; full STEMI dose acutely defensible per ESC 2018 pregnancy (PMID 30165544)
2. clopidogrel 600 mg load → 75 mg daily × 12 mo PO load + daily × 12 mo (p2y12_inhibitor, first line) — Pregnancy Class B; PREFERRED P2Y12 in pregnancy due to longer safety record vs ticagrelor (Class C, data limited); plan to interrupt 5-7 d before delivery if elective + consider bridging with bivalirudin
3. heparin_unfractionated 70-100 U/kg IV bolus then infusion to aPTT 1.5-2.5×control IV bolus + infusion (parenteral_anticoagulant, first line) — Does NOT cross placenta; reversible with protamine; PREFERRED over LMWH peri-cath/peri-delivery for reversibility
4. metoprolol 25-50 mg PO BID; titrate PO BID (beta_blocker_b1_selective, first line) — Pregnancy Class C but safety record supports use; AVOID atenolol (Class D — FGR); labetalol Class C also acceptable; CAPRICORN extrapolation
5. labetalol 100-200 mg PO BID; titrate PO BID (beta_blocker_alpha_beta, first line) — Pregnancy preferred BB; ACOG 2019 first-line for HTN in pregnancy
6. atorvastatin HOLD in pregnancy unless absolute necessity (FDA Class X historical; 2021 FDA reconsidered for high-risk patients) PO HOLD (statin, comorbidity specific) — FDA 2021 statement: statin contraindication softened — case-by-case for high-risk patients; pravastatin lowest fetal exposure if needed; restart 6 wk postpartum (or only pravastatin if breastfeeding)
7. warfarin AVOID throughout pregnancy PO AVOID (vitamin_k_antagonist, comorbidity specific) — Warfarin embryopathy 6-12 wk + fetal hemorrhage throughout; if AC indicated → LMWH (does not cross placenta); restart warfarin postpartum if needed

Setting playbook (outpatient) — Long-term cardiology surveillance for young female with history of pregnancy STEMI; secondary prevention bundle; future pregnancy counseling (high recurrence risk; preconception cardiology consult mandatory)
8. continue full secondary-prevention bundle ASA 81 + ticagrelor or clopidogrel + statin + BB + ACEi/ARNI if EF<40 PO as scheduled — post-STEMI (AHA 2025)

Non-pharmacologic actions:
- Future pregnancy: preconception cardiology consult MANDATORY
- Avoid OCPs/HRT (estrogen procoagulant)
- Smoking cessation absolute
- Weight + DM + HTN optimization

AVOID / contraindication checks:
- Fibrinolysis_AVOID_in_pregnancy (ICH risk + placental abruption + fetal hemorrhage)
- Warfarin_AVOID_in_pregnancy (teratogen 6 12 wk + fetal hemorrhage throughout)
- Atenolol_AVOID_in_pregnancy (Class D — FGR)
- ACEi_ARB_AVOID_in_pregnancy (renal dysgenesis 2nd/3rd trimester; postpartum okay)
- Ticagrelor_PREFER_clopidogrel_in_pregnancy (limited safety data)
- Statin_HOLD_unless_absolute_necessity (FDA Class X historical; 2021 reconsidered case by case)
- CT_PE_AVOID_first_line_use_shielded_echo_or_cath (radiation to fetus)

Monitoring

Regimen monitoring:
- continuous fetal monitoring if gestational age 24wk and viable
- OB co management for delivery planning and preeclampsia screen
- echo post PCI for LV function and thrombus
- aPTT during UFH infusion (LMWH anti-Xa if shifted to LMWH outpatient)

Setting (outpatient) monitoring:
- Annual lipid + A1c + EF

Follow-up plan: Multidisciplinary cardiology + MFM + lactation: vaginal delivery preferred unless obstetric/cardiac indication; postpartum revascularization if not done acutely; lactation safe meds (avoid amiodarone, ACEi okay postpartum); statin restart 6 wk postpartum if not breastfeeding (or use pravastatin-only if breastfeeding per limited data); contraception planning (avoid estrogen — IUD/progestin preferred)
- Close-out criterion: delivery plan + postpartum medication plan + contraception booked

Monitoring phase: Telemetry, fetal monitoring per gestational age, daily exam; serial echo for thrombus + LV function; OB monitoring for preeclampsia (overlapping risk)

Disposition

Current setting: outpatient — Long-term cardiology surveillance for young female with history of pregnancy STEMI; secondary prevention bundle; future pregnancy counseling (high recurrence risk; preconception cardiology consult mandatory)

Disposition criteria:
- Long-term continuation; cross-link to cardio.ascvd.chronic.v1 for chronic CAD management

Escalation triggers (move to higher acuity):
- Recurrent ACS → cath + reassess for SCAD vs atherosclerotic vs APS
- Pregnancy in setting of prior pregnancy STEMI → MFM + cardiology high-risk pregnancy clinic

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pregnant patient exposed to fibrinolysis (alteplase/tenecteplase) — ICH risk + placental abruption + fetal hemorrhage; should NEVER be given in pregnancy unless life-threatening PE/stroke with no alternative
- [LIFE_THREATENING] Fetal distress on continuous monitoring during acute STEMI management (post-PCI or stabilization) requiring emergent delivery while maternal antiplatelet/anticoagulation active
- [SEVERE] Pregnant patient with cocaine on UDS + STEMI — placental abruption + fetal cocaine exposure + maternal vasospasm; AVOID pure beta-blocker (unopposed alpha worsens)

Citations

- 2025 ACC/AHA ACS + ESC 2018 Pregnancy CV Disease + AHA 2024 Pregnancy + ACS Statement + ACOG Pregnancy Guidelines [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 30165544) [PMID:30165544](https://pubmed.ncbi.nlm.nih.gov/30165544/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 31475795) [PMID:31475795](https://pubmed.ncbi.nlm.nih.gov/31475795/)

Last reconciled with current guidelines: 2026-05-15.
References