Clinical Commander

Back to dossier
cardio.stemi.left-main.v1PRODUCTION
cardio.stemi.left-main.v1

Left main coronary artery (LMCA) STEMI-equivalent

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

LMCA STEMI-equivalent = aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads pattern; HIGH mortality without urgent revasc; cardiogenic shock typical; route to cardio.stemi.core.v1 for the reperfusion arc; CABG vs PCI decision is the dominant strategic question

Inputs
1
Actions
0
Advance rule
Set
Advance when

LMCA-equivalent ECG confirmed

Patient inputs (8)

Older patients have higher peri-revasc mortality; informs PCI vs CABG decision per SYNTAX score interaction with age

Contrast nephropathy + DOAC dosing; CKD interacts with surgical-vs-PCI decision (CABG often preferred in CKD per SYNTAX subset)

aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads = LMCA-equivalent or proximal-LAD-pre-septal or 3VD; high mortality without urgent revasc

Confirms infarct; LMCA-territory infarcts produce massive troponin rise reflecting large jeopardized myocardium

LV function (often severely depressed); RV function; mechanical complications

Hypotension highly prevalent — LMCA territory occlusion typically produces SCAI C-E shock; informs urgent MCS need

Lactate ≥2 supports SCAI C+ shock staging — anchor for MCS escalation per DanGer Shock PMID 38587234

LMCA lesion confirmation + SYNTAX score for CABG-vs-PCI decision; LMCA bifurcation morphology for DK-CRUSH technical planning

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

Severity triggers (4)

4 need judgement
  • informationallife_threateninglmca_stemi_with_cardiogenic_shock
    LMCA-equivalent STEMI + SBP <90 + lactate ≥2 — SCAI C+ cardiogenic shock; high probability given LMCA territory size
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglmca_stemi_with_biventricular_failure
    LMCA-equivalent STEMI + biventricular failure (RV + LV); refractory to Impella CP or escalating support
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglmca_pci_bifurcation_complication
    LMCA bifurcation PCI (left main → LAD/LCx) with side-branch occlusion or stent thrombosis intra-procedure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelmca_stemi_cabg_vs_pci_decision
    LMCA-equivalent STEMI + Heart Team CABG-vs-PCI decision — informed by SYNTAX score, comorbidity, frailty, surgical eligibility, hemodynamic stability
    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

LMCA STEMI-equivalent revascularization phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen with CABG-vs-PCI strategic axis + MCS bias
axis: lmca_stemi_revascularization_phenotype
Selected axis "LMCA STEMI-equivalent revascularization phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen with CABG-vs-PCI strategic axis + MCS bias" 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; do NOT hold for CABG (continue peri-CABG per AHA 2025)
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID — HOLD if CABG decided within 5 d; consider cangrelor bridge • PO • BID × 12 mo if PCI
    triggers: stemi_pci_planned
    PLATO PMID 19717846; ticagrelor washout 5 d before CABG required to mitigate bleeding (AHA 2025)
    rxcui 1116632
  • cangrelor
    comorbidity specific
    p2y12_inhibitor_iv_short_acting
    30 mcg/kg IV bolus + 4 mcg/kg/min infusion • IV • bridge to oral P2Y12 or off for CABG
    triggers: cabg_likely_within_24h, oral_p2y12_not_feasible
    Short half-life IV P2Y12 — useful bridge if CABG decision pending or if cardiogenic shock with absent gut absorption
    rxcui 1656052
  • unfractionated heparin
    first line
    anticoagulant_indirect_at_iii
    70-100 U/kg IV bolus then per ACT • IV • titrated
    triggers: pci_planned, mcs_planned
    AHA 2025 Class I PCI anticoagulant; also required for Impella/ECMO MCS
    rxcui 5224
  • metoprolol
    contraindication substitute
    beta_blocker
    DEFER until shock resolves and rhythm stable • PO • deferred
    triggers: post_lmca_no_cs_no_brady
    BB normally Class I post-MI, but AVOID/defer if SCAI B+ shock or hemodynamic instability; reintroduce only after shock resolution + ≥48h hemodynamic stability — encoded as contraindication_substitute (avoid in acute CS 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 + GDMT • PO • as scheduled
    trigger: post-LMCA-MI
    AHA 2025; EXCEL for DAPT duration

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads (LMCA equivalent / 3-vessel disease); Severe ischemic chest pain + hypotension/shock + LMCA-equivalent ECG → emergent cath + MCS standby; Known or newly identified LMCA lesion on angio in acute coronary syndrome.

Objective

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

Assessment

**Left main coronary artery (LMCA) STEMI-equivalent** (cardio.stemi.left-main.v1).
Scope: LMCA STEMI-equivalent = aVR ST↑ ≥1 mm + diffuse ST↓ ≥1 mm in ≥6 leads pattern; HIGH mortality without urgent revasc; cardiogenic shock typical; route to cardio.stemi.core.v1 for the reperfusion arc; CABG vs PCI decision is the dominant strategic question

No severity triggers fired against current inputs.

Plan

Regimen axis: **LMCA STEMI-equivalent revascularization phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen with CABG-vs-PCI strategic axis + MCS bias**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; same as parent; do NOT hold for CABG (continue peri-CABG per AHA 2025)
2. ticagrelor 180 mg load → 90 mg BID — HOLD if CABG decided within 5 d; consider cangrelor bridge PO BID × 12 mo if PCI (p2y12_inhibitor, first line) — PLATO PMID 19717846; ticagrelor washout 5 d before CABG required to mitigate bleeding (AHA 2025)
3. cangrelor 30 mcg/kg IV bolus + 4 mcg/kg/min infusion IV bridge to oral P2Y12 or off for CABG (p2y12_inhibitor_iv_short_acting, comorbidity specific) — Short half-life IV P2Y12 — useful bridge if CABG decision pending or if cardiogenic shock with absent gut absorption
4. unfractionated heparin 70-100 U/kg IV bolus then per ACT IV titrated (anticoagulant_indirect_at_iii, first line) — AHA 2025 Class I PCI anticoagulant; also required for Impella/ECMO MCS
5. metoprolol DEFER until shock resolves and rhythm stable PO deferred (beta_blocker, contraindication substitute) — BB normally Class I post-MI, but AVOID/defer if SCAI B+ shock or hemodynamic instability; reintroduce only after shock resolution + ≥48h hemodynamic stability — encoded as contraindication_substitute (avoid in acute CS phenotype, restart in chronic management arm)

Setting playbook (outpatient) — Long-term cardiology surveillance: secondary prevention bundle maintenance; high ICD-eligibility rate (large infarct typical); cardiac rehab completion; late surgical complications surveillance if CABG performed
6. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT PO as scheduled — post-LMCA-MI (AHA 2025; EXCEL for DAPT duration)

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

AVOID / contraindication checks:
- Hold_oral_p2y12_5d_pre_cabg_to_reduce_bleeding (AHA 2025)
- Beta_blocker_avoid_in_acute_cardiogenic_shock (AHA 2025)
- Cangrelor_2_min_offset_acceptable_for_emergent_cabg (label)
- Dapt_full_12mo_post_lmca_pci (AHA 2025 + EXCEL)

Monitoring

Regimen monitoring:
- serial lactate q2-4h during mcs
- arterial line throughout acute phase
- echo at 24-72h for lv recovery and mcs weaning assessment
- pulmonary artery catheter consideration for mcs titration

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

Follow-up plan: Cardiology + cardiac surgery follow-up; echo at 30-90 d for LVEF + ICD eligibility (MADIT-II); cardiac rehab; advanced HF eval if EF <30 not recovering
- Close-out criterion: cardiac rehab booked + ICD pathway documented

Monitoring phase: CICU/SICU telemetry + arterial line + PA catheter consideration; MCS weaning protocol; serial echo for LV recovery; vigilance for mechanical complications

Disposition

Current setting: outpatient — Long-term cardiology surveillance: secondary prevention bundle maintenance; high ICD-eligibility rate (large infarct typical); cardiac rehab completion; late surgical complications surveillance if CABG performed

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 / transplant
- Recurrent angina → cath re-eval (in-stent restenosis or graft failure)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] LMCA-equivalent STEMI + SBP <90 + lactate ≥2 — SCAI C+ cardiogenic shock; high probability given LMCA territory size
- [LIFE_THREATENING] LMCA-equivalent STEMI + biventricular failure (RV + LV); refractory to Impella CP or escalating support
- [LIFE_THREATENING] LMCA bifurcation PCI (left main → LAD/LCx) with side-branch occlusion or stent thrombosis intra-procedure

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + ESC/EACTS 2018 Revascularization + SYNTAX + EXCEL + DK-CRUSH [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 27199061) [PMID:27199061](https://pubmed.ncbi.nlm.nih.gov/27199061/)

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