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cardio.stemi.late-presenter.v1PRODUCTION
cardio.stemi.late-presenter.v1

Late-presenter STEMI (>12 h after symptom onset)

cardiologyacuteadult
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10/12 authored

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

Current phase

Frame

Detailed

Late-presenter STEMI = symptom onset >12 h ago. Decision axis: ongoing ischemia / shock / arrhythmia → emergent reperfusion (Class I); asymptomatic 12-72 h + viable myocardium → IIa delayed PCI; >72 h asymptomatic stable → OMT only per OAT

Inputs
1
Actions
0
Advance rule
Set
Advance when

time-from-onset stratification documented

Patient inputs (9)

Elderly more likely to be late presenters; STREAM-2 half-dose TNK considerations

Contrast nephropathy risk for cath + DOAC dosing post-MI

Time-from-onset is the central decision axis: <12 h → emergent PCI; 12-72 h asymptomatic + viable → IIa PCI; >72 h asymptomatic stable → OMT only (OAT)

Persistent ST elevation vs evolved Q-waves drives reperfusion decision; rapidly evolving Q-waves → completed infarction with less viability

Trajectory (rising vs peaked-and-falling) helps localize where in the infarct timeline patient sits

Bedside echo: LVEF, regional wall motion, LV thrombus (more common in late presenters), aneurysm, mechanical complications

Persistent / recurrent chest pain or dynamic ECG → reperfusion still Class I regardless of time window

Hypotension / shock → emergent reperfusion regardless of time window (SCAI 2022)

Cardiac MRI with LGE / dobutamine stress echo / PET — for asymptomatic 12-72 h presenters to identify candidates for delayed PCI; viable myocardium >50% supplies revascularization benefit

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

Severity triggers (4)

4 need judgement
  • informationallife_threateninglate_stemi_with_shock_at_presentation
    Late-presenter STEMI + SBP <90 + lactate ≥2 + hypoperfusion — SCAI C+ at presentation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_in_late_presenter
    New harsh holosystolic murmur OR pericardial effusion on echo OR sudden hemodynamic deterioration → free-wall rupture / VSR / papillary rupture (peak risk 3-7 d post-MI, more common in late presenters who never reperfused)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelv_thrombus_in_late_presenter_on_echo
    LV thrombus on echo at 5-7 d post late STEMI — markedly higher rate in late presenters with anterior territory + EF <40 + apical akinesia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereventricular_aneurysm_with_thrombus
    Late-presenter STEMI with developed ventricular aneurysm (typically anterior, apical) + mural thrombus on cardiac MRI / echo
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Late-presenter STEMI temporal phenotype — adds to parent cardio.stemi.core.v1 regimen if reperfusion indicated; otherwise OMT-only with secondary prevention bundle
axis: late_presenter_stemi_temporal_phenotype
Selected axis "Late-presenter STEMI temporal phenotype — adds to parent cardio.stemi.core.v1 regimen if reperfusion indicated; otherwise OMT-only with secondary prevention bundle" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed • PO • load + 81 mg daily indefinitely
    triggers: late_stemi_confirmed
    AHA 2025 ACS Class I — secondary prevention regardless of reperfusion decision
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo if PCI performed
    triggers: late_stemi_pci_planned
    PLATO PMID 19717846; only if PCI performed
    rxcui 1116632
  • clopidogrel
    second line
    p2y12_inhibitor
    300 mg load → 75 mg daily • PO • daily × 12 mo if no PCI but late STEMI with persistent ECG changes
    triggers: late_stemi_no_pci_omt_only, ticagrelor_contraindication
    OMT-only late STEMI: ASA + clopidogrel for secondary prevention per ACC/AHA 2025
    rxcui 309362
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily indefinitely
    triggers: late_stemi_confirmed
    PROVE-IT PMID 15007110; high-intensity statin regardless of reperfusion
    rxcui 83367
  • carvedilol
    first line
    beta_blocker_nonselective
    3.125 mg BID titrate • PO • BID
    triggers: late_stemi_with_lv_dysfunction, ef_below_40
    CAPRICORN PMID 11356436 — post-MI BB benefit independent of reperfusion
    rxcui 20352
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR 2-3 × 3 mo • PO • daily
    triggers: lv_thrombus_on_echo, ventricular_aneurysm_with_thrombus
    Late presenters have higher LV thrombus / aneurysm rate; AHA 2022 Class IIa 3-mo AC
    rxcui 11289
  • tenecteplase
    rescue
    thrombolytic_fibrin_specific
    half-dose if age ≥75 (STREAM-2); standard weight-based otherwise • IV • single bolus
    triggers: late_stemi_no_pci_capability_within_120_min, ongoing_ischemia_persistent_st_elevation
    STREAM-2 (Armstrong 2020) — half-dose TNK in elderly; only when PCI not feasible AND ongoing ischemia
    rxcui 259280

outpatient playbook — drug actions (1)

  1. 1. continue secondary-prevention bundle
    rxcui 243670
    ASA 81 + P2Y12 × 12 mo + atorvastatin 80 + GDMT • PO • as scheduled
    trigger: post-late-STEMI
    AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Ischemic chest pain with onset >12 h ago + persistent ST elevation; Persistent ST elevation + evolving Q waves on ECG (late STEMI); Delayed presentation (>12 h) with ongoing chest pain or hemodynamic instability — reperfusion still indicated.

Objective

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

Assessment

**Late-presenter STEMI (>12 h after symptom onset)** (cardio.stemi.late-presenter.v1).
Scope: Late-presenter STEMI = symptom onset >12 h ago. Decision axis: ongoing ischemia / shock / arrhythmia → emergent reperfusion (Class I); asymptomatic 12-72 h + viable myocardium → IIa delayed PCI; >72 h asymptomatic stable → OMT only per OAT

No severity triggers fired against current inputs.

Plan

Regimen axis: **Late-presenter STEMI temporal phenotype — adds to parent cardio.stemi.core.v1 regimen if reperfusion indicated; otherwise OMT-only with secondary prevention bundle**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily indefinitely (antiplatelet_cox1, first line) — AHA 2025 ACS Class I — secondary prevention regardless of reperfusion decision
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo if PCI performed (p2y12_inhibitor, first line) — PLATO PMID 19717846; only if PCI performed
3. clopidogrel 300 mg load → 75 mg daily PO daily × 12 mo if no PCI but late STEMI with persistent ECG changes (p2y12_inhibitor, second line) — OMT-only late STEMI: ASA + clopidogrel for secondary prevention per ACC/AHA 2025
4. atorvastatin 80 mg PO daily indefinitely (statin_high_intensity, first line) — PROVE-IT PMID 15007110; high-intensity statin regardless of reperfusion
5. carvedilol 3.125 mg BID titrate PO BID (beta_blocker_nonselective, first line) — CAPRICORN PMID 11356436 — post-MI BB benefit independent of reperfusion
6. warfarin 5 mg daily; INR 2-3 × 3 mo PO daily (vitamin_k_antagonist, comorbidity specific) — Late presenters have higher LV thrombus / aneurysm rate; AHA 2022 Class IIa 3-mo AC
7. tenecteplase half-dose if age ≥75 (STREAM-2); standard weight-based otherwise IV single bolus (thrombolytic_fibrin_specific, rescue) — STREAM-2 (Armstrong 2020) — half-dose TNK in elderly; only when PCI not feasible AND ongoing ischemia

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
8. continue secondary-prevention bundle ASA 81 + P2Y12 × 12 mo + atorvastatin 80 + GDMT PO as scheduled — post-late-STEMI (AHA 2025)

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

AVOID / contraindication checks:
- Tenecteplase_avoid_recent_stroke_or_intracranial_hemorrhage (FDA label)
- Tenecteplase_avoid_active_bleeding (FDA label)
- Warfarin_avoid_active_bleeding (AHA 2022)
- No_thrombolytic_after_24h_from_symptom_onset (no benefit per LATE/EMERAS trials)

Monitoring

Regimen monitoring:
- echo at 5-7d for lv thrombus screen (peak thrombus formation period; higher rate in late presenters)
- echo at 40d for lvef reassessment for icd eligibility (MADIT-II)
- INR q week during warfarin initiation
- cardiac MRI at 6-12 weeks for viability quantification if delayed revasc considered

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); cardiac rehab; secondary prevention bundle maintenance
- Close-out criterion: ICD/WCD pathway + cardiac rehab booked

Monitoring phase: Telemetry, daily exam for new murmur (mechanical complications), echo at 5-7 d for LV thrombus screen, 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] Late-presenter STEMI + SBP <90 + lactate ≥2 + hypoperfusion — SCAI C+ at presentation
- [LIFE_THREATENING] New harsh holosystolic murmur OR pericardial effusion on echo OR sudden hemodynamic deterioration → free-wall rupture / VSR / papillary rupture (peak risk 3-7 d post-MI, more common in late presenters who never reperfused)
- [SEVERE] LV thrombus on echo at 5-7 d post late STEMI — markedly higher rate in late presenters with anterior territory + EF <40 + apical akinesia

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + OAT trial framework for late presenters [PMID:17112106](https://pubmed.ncbi.nlm.nih.gov/17112106/)
- Cited evidence (PMID 37622670) [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 11907286) [PMID:11907286](https://pubmed.ncbi.nlm.nih.gov/11907286/)

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