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cardio.stemi.inferior.v1PRODUCTION
cardio.stemi.inferior.v1

Inferior wall STEMI (RCA / LCx culprit)

cardiologyacuteadult
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10/12 authored

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

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Detailed

Inferior STEMI = RCA (most common, ≈80%) or LCx culprit; smaller territory than anterior typically; characteristic bradyarrhythmia + AV-block + RV-extension complication profile; route to cardio.stemi.core.v1 for the reperfusion arc

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inferior STEMI confirmed on ECG

Patient inputs (9)

Older patients have higher AV-block risk after inferior MI

Contrast nephropathy + DOAC dosing if AF post-MI

II/III/aVF ST↑ defines inferior; ST↑ III > II suggests RCA, ST↑ II > III + I/aVL ST↑ suggests LCx; ALWAYS obtain V4R for RV-extension screening

V4R ST↑ ≥1 mm = RV extension → route to cardio.stemi.right-ventricular.v1; Class I obligatory in inferior STEMI per AHA 2025

Confirms infarct; smaller absolute peak vs anterior MI (smaller territory typically)

LV + RV function, inferior wall motion, mitral apparatus (papillary rupture more often posteromedial in inferior MI)

Hypotension in inferior MI — distinguish vagal (responds to atropine + fluids) from RV extension (preload-dependent)

Bradyarrhythmia common in inferior MI (Berger PMID 1735156); transient AV block in 12-20%

RCA vs LCx culprit confirmation; complete revasc decision per COMPLETE PMID 31475795

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Severity triggers (5)

5 need judgement
  • informationallife_threateningposteromedial_papillary_muscle_rupture
    New harsh apical/axillary holosystolic murmur post-inferior-MI + acute pulmonary edema → posteromedial papillary rupture (single-vessel blood supply from PDA, more vulnerable than anterolateral)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinferior_stemi_with_high_grade_av_block
    2°-3° AV block in inferior MI; usually transient (resolves <48h with reperfusion) but can be symptomatic — Mobitz I with hypotension or complete heart block
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinferior_stemi_with_v4r_st_elevation
    V4R ST↑ ≥1 mm in inferior STEMI = RV extension (proximal RCA) — preload-dependent
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinferior_stemi_with_persistent_hypotension_post_atropine
    Inferior STEMI + SBP <90 not responsive to atropine + fluids — assess for RV extension, mechanical complication, or evolving cardiogenic shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_high_grade_av_block_beyond_5_days
    Mobitz II or 3° AV block persisting >5d post-inferior-MI despite reperfusion
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Inferior STEMI complication phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen
axis: inferior_stemi_complication_phenotype
Selected axis "Inferior 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
  • atropine
    rescue
    antimuscarinic
    0.5 mg IV q3-5 min, max 3 mg • IV • PRN
    triggers: symptomatic_bradycardia, av_block_with_hypotension
    Vagal-mediated bradycardia (Bezold-Jarisch reflex) common in inferior MI; first-line per Kusumoto 2018 PMID 30412709
    rxcui 1223
  • metoprolol
    contraindication substitute
    beta_blocker
    12.5-25 mg PO BID — DEFER until rhythm stable • PO • deferred
    triggers: post_inferior_mi_no_av_block_no_brady
    BB normally Class I post-MI, but AVOID/defer in acute inferior MI if HR <60, 2°-3° AV block, or hypotension; reintroduce after 48h once rhythm stable — encoded as contraindication_substitute (avoid in this phenotype, restart in chronic management arm)
    rxcui 6918

outpatient playbook — drug actions (1)

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

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ST elevation II/III/aVF + reciprocal ST↓ I/aVL (inferior STEMI); Ischemic chest pain + inferior STEMI ECG → emergent cath within 90 min; Inferior STEMI on standard ECG → mandatory V4R lead to screen for RV extension.

Objective

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

Assessment

**Inferior wall STEMI (RCA / LCx culprit)** (cardio.stemi.inferior.v1).
Scope: Inferior STEMI = RCA (most common, ≈80%) or LCx culprit; smaller territory than anterior typically; characteristic bradyarrhythmia + AV-block + RV-extension complication profile; route to cardio.stemi.core.v1 for the reperfusion arc

No severity triggers fired against current inputs.

Plan

Regimen axis: **Inferior 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. atropine 0.5 mg IV q3-5 min, max 3 mg IV PRN (antimuscarinic, rescue) — Vagal-mediated bradycardia (Bezold-Jarisch reflex) common in inferior MI; first-line per Kusumoto 2018 PMID 30412709
4. metoprolol 12.5-25 mg PO BID — DEFER until rhythm stable PO deferred (beta_blocker, contraindication substitute) — BB normally Class I post-MI, but AVOID/defer in acute inferior MI if HR <60, 2°-3° AV block, or hypotension; reintroduce after 48h once rhythm stable — encoded as contraindication_substitute (avoid in this phenotype, restart in chronic management arm)

Setting playbook (outpatient) — Long-term cardiology surveillance: secondary prevention bundle maintenance; lower ICD-eligibility rate (smaller infarct typical); cardiac rehab completion
5. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + BB PO as scheduled — post-inferior-MI (AHA 2025)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase
- Driving restriction per state law if pacing or VF

AVOID / contraindication checks:
- Beta_blocker_avoid_in_acute_inferior_mi_if_av_block_or_brady (AHA 2025 / Kusumoto 2018)
- Atropine_caution_in_glaucoma_and_obstructive_uropathy (label)
- Transcutaneous_pacing_for_symptomatic_high_grade_av_block (Kusumoto 2018 Class I)

Monitoring

Regimen monitoring:
- continuous telemetry x 72h for av block recurrence
- V4R lead within 10 min of inferior stemi recognition
- serial HR and BP q15min first 2h

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

Follow-up plan: Cardiology follow-up; echo at 40 d for LVEF reassessment; cardiac rehab; lower ICD-eligibility rate than anterior (smaller infarct typically)
- Close-out criterion: cardiac rehab booked + EF re-assessed

Monitoring phase: Telemetry continuous; daily exam for new murmur (papillary); rhythm follow-up — most AV block resolves <48h with reperfusion; if persistent >5d consider permanent pacing per Kusumoto 2018

Disposition

Current setting: outpatient — Long-term cardiology surveillance: secondary prevention bundle maintenance; lower ICD-eligibility rate (smaller infarct typical); cardiac rehab completion

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

Escalation triggers (move to higher acuity):
- EF declining despite GDMT → advanced HF eval
- Recurrent angina → cath re-eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New harsh apical/axillary holosystolic murmur post-inferior-MI + acute pulmonary edema → posteromedial papillary rupture (single-vessel blood supply from PDA, more vulnerable than anterolateral)
- [SEVERE] 2°-3° AV block in inferior MI; usually transient (resolves <48h with reperfusion) but can be symptomatic — Mobitz I with hypotension or complete heart block
- [SEVERE] V4R ST↑ ≥1 mm in inferior STEMI = RV extension (proximal RCA) — preload-dependent

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + 2018 ACC/AHA/HRS Bradycardia Guideline [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 1735156) [PMID:1735156](https://pubmed.ncbi.nlm.nih.gov/1735156/)

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