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cardio.stemi.lupus-coronary-vasculitis.v1PRODUCTION
cardio.stemi.lupus-coronary-vasculitis.v1

STEMI — SLE-associated coronary vasculitis (immune-complex inflammation + premature CAD)

cardiologyacuteadult
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10/12 authored

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

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Detailed

STEMI in SLE patient with three differential drivers: (1) immune-complex coronary VASCULITIS (this engine — IVUS/OCT shows vessel-wall inflammation, active SLE serology, requires pulse immunosuppression); (2) premature ATHEROSCLEROTIC CAD (route to parent cardio.stemi.core.v1 + secondary prevention); (3) APS THROMBOSIS (route to cardio.stemi.antiphospholipid-syndrome-related.v1 if APS antibodies + thrombus disproportionate to plaque)

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SLE-associated etiology framed

Patient inputs (11)

SLE serology bundle: ANA (≥1:80 + clinical = SLE), anti-dsDNA + anti-Smith (specific), C3/C4 (low in active disease) — confirms active immunologic activity at index event

APS antibody panel — 30-50% co-occurrence with SLE; if predominant → route to cardio.stemi.antiphospholipid-syndrome-related.v1 (warfarin INR 2.5-3.5 lifelong vs immunosuppression)

Young SLE patients (20s-40s, 90% women) with STEMI raise vasculitis vs premature atherosclerosis vs APS-thrombosis suspicion

Lupus nephritis baseline + contrast nephropathy + DOAC/AC dosing

Established SLE (ACR/EULAR 2019 criteria) or active features (malar rash, arthritis, serositis, cytopenias, nephritis, neuropsych) — central diagnostic anchor

STEMI territory localization; pericarditis pattern overlap common in SLE

Quantifies infarct burden; persistent elevation may suggest ongoing vasculitis vs single-event plaque rupture

LVEF + regional wall motion + pericardial effusion (lupus pericarditis common comorbid) + valve assessment (Libman-Sacks endocarditis)

Hypotension + STEMI in lupus → cardiogenic shock high probability; lupus nephritis-related volume status complicates hemodynamics

Diagnostic + therapeutic gold standard; lupus vasculitis often shows long diffuse stenoses, multivessel involvement, or ostial disease vs discrete plaque rupture

IVUS/OCT distinguishes vasculitic vessel-wall inflammation (intramural hemorrhage, eccentric thickening, no calcified plaque) from atherosclerotic plaque rupture/erosion (lipid core, thin-cap fibroatheroma) — drives vasculitis-specific immunosuppression decision

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Severity triggers (6)

6 need judgement
  • informationallife_threateningsle_active_coronary_vasculitis_with_stemi
    IVUS/OCT confirms vessel-wall inflammation + active SLE serology (low C3/C4, elevated dsDNA) at index STEMI → pulse steroids + cyclophosphamide/MMF immediately
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsle_aps_overlap_predominant_thrombosis
    Triple-positive APS antibodies + thrombus disproportionate to plaque on IVUS/OCT → APS-driven coronary thrombosis predominant; lifelong warfarin INR 2.5-3.5 vs immunosuppression-only
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsle_caps_with_concurrent_stemi
    Catastrophic APS — multi-organ thrombosis in <1 wk + STEMI + histopathologic small-vessel thrombosis → mortality 50% without aggressive triple therapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsle_sudden_cardiac_death_risk_after_event
    EF <35 + non-sustained VT on telemetry post-SLE-STEMI → SCD risk in 40-90 d window (often young patients with lifetime ICD implications)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresle_libman_sacks_endocarditis_with_embolic_event
    New-onset stroke / TIA / systemic embolism with vegetation on echo + STEMI patient → Libman-Sacks endocarditis + arterial thromboembolism
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereimmunosuppression_related_infection_during_taper
    New fever / infiltrate / cytopenia during high-dose steroid + cyclophosphamide/MMF treatment — opportunistic infection (PJP, CMV, fungal, TB reactivation) high risk
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

SLE coronary vasculitis + STEMI regimen — combines acute reperfusion with pulse immunosuppression and lifelong hydroxychloroquine + secondary prevention; APS overlap drives concurrent warfarin if predominant
axis: lupus_coronary_vasculitis_stemi_phenotype
Selected axis "SLE coronary vasculitis + STEMI regimen — combines acute reperfusion with pulse immunosuppression and lifelong hydroxychloroquine + secondary prevention; APS overlap drives concurrent warfarin if predominant" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed load → 81 mg daily lifelong • PO • daily indefinitely
    triggers: sle_stemi_confirmed
    AHA 2025 ACS Class I + EULAR 2023 (PMID 36750244) — ASA in SLE arterial event; concurrent with warfarin if APS overlap predominant
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo standard DAPT, then reassess given vasculitis status
    triggers: sle_stemi_pci_planned
    PLATO PMID 19717846; standard ACS DAPT applies; duration extension if persistent vasculitis activity
    rxcui 1116632
  • unfractionated_heparin
    first line
    parenteral_anticoagulant
    70-100 U/kg IV bolus + activated infusion • IV • bolus + infusion at PCI; transition to oral AC if APS overlap
    triggers: sle_stemi_pci_planned, aps_overlap_thrombosis
    AHA 2025 Class I for PCI; UFH preferred over LMWH in APS overlap (anti-Xa more reliable than aPTT if LA prolongs baseline)
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg daily lifelong • PO • daily
    triggers: sle_stemi_confirmed
    PROVE-IT PMID 15007110; high-intensity statin lifelong post-MI; pleiotropic anti-inflammatory effect particularly relevant for SLE endothelial dysfunction
    rxcui 83367
  • hydroxychloroquine
    first line
    antimalarial_dmard
    200-400 mg daily (≤5 mg/kg ideal weight) • PO • daily lifelong
    triggers: sle_diagnosis_confirmed, sle_stemi_index_event
    EULAR 2023 (PMID 36750244) Class I — HCQ foundational for ALL SLE patients regardless of activity; cardiovascular benefit (Ruiz-Irastorza 2010 PMID 20132533) — reduces thrombosis + flares + lipid improvement; safe in pregnancy
    rxcui 5521
  • methylprednisolone
    rescue
    corticosteroid_iv_pulse
    1 g IV daily × 3-5 days • IV • pulse × 3-5 d
    triggers: confirmed_sle_coronary_vasculitis_via_ivus_oct_or_active_serology, severe_organ_threatening_sle_flare
    EULAR 2023 — pulse steroids for severe organ-threatening lupus including coronary vasculitis; bridge to oral prednisone + steroid-sparing agent
    rxcui 6902
  • prednisone
    first line
    corticosteroid_oral
    1 mg/kg PO daily, taper over months • PO • daily with taper schedule
    triggers: post_pulse_steroid_taper, maintenance_sle_immunosuppression
    EULAR 2023 (PMID 36750244) — oral steroid taper after pulse; goal is steroid minimization with steroid-sparing agent
    rxcui 8640
  • cyclophosphamide
    add on
    cytotoxic_alkylating
    500-1000 mg/m² IV monthly × 6 (or low-dose Euro-Lupus 500 mg q2w × 6) • IV • monthly × 6
    triggers: severe_organ_threatening_sle_with_coronary_vasculitis, refractory_to_steroids_alone
    EULAR 2023 — cyclophosphamide for severe organ-threatening SLE; coronary vasculitis qualifies; gonadotoxic — counseling required
    rxcui 3002
  • mycophenolate_mofetil
    second line
    immunosuppressant_imp_dh_inhibitor
    1-3 g/d divided BID • PO • BID
    triggers: cyclophosphamide_alternative, less_gonadotoxic_preference, maintenance_immunosuppression
    ALMS PMID 19369404 — MMF non-inferior to cyclophosphamide for severe SLE; less gonadotoxic; preferred for women of reproductive age (but teratogenic — switch off before conception)
    rxcui 68149
  • rituximab
    rescue
    anti_cd20_monoclonal_antibody
    1 g IV × 2 doses (days 0 + 14) • IV • 2 doses
    triggers: refractory_sle_coronary_vasculitis_despite_steroids_+_cyclophosphamide_or_mmf
    EULAR 2023 — rituximab off-label for refractory SLE; supported by observational series for organ-threatening disease
    rxcui 121191
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR target 2.5-3.5 if APS overlap predominant • PO • daily lifelong if APS overlap
    triggers: aps_overlap_with_arterial_thrombosis_predominant, triple_positive_aps_serology
    EULAR 2019 APS Class I; TRAPS PMID 30196097 — warfarin INR 2.5-3.5 lifelong if APS overlap is predominant driver (route to cardio.stemi.antiphospholipid-syndrome-related.v1)
    rxcui 11289
  • carvedilol
    first line
    beta_blocker_nonselective
    3.125 mg BID titrate • PO • BID
    triggers: sle_stemi_with_lv_dysfunction, ef_below_40
    CAPRICORN PMID 11356436 — post-MI BB benefit; carvedilol preferred for HFrEF GDMT
    rxcui 20352
  • sacubitril-valsartan
    add on
    arni
    24/26 mg BID titrate • PO • BID
    triggers: sle_stemi_with_ef_below_40_post_event
    PIONEER-HF PMID 30403955; ACC/AHA 2022 HF Class I if HFrEF persists post-MI
    rxcui 1656328

outpatient playbook — drug actions (1)

  1. 1. continue lifelong bundle
    rxcui 243670
    ASA 81 + warfarin INR 2.5-3.5 (if APS overlap) + atorvastatin 80 + HCQ 400 + GDMT if HFrEF + maintenance immunosuppression per rheumatology • PO • as scheduled
    trigger: SLE coronary disease lifelong
    EULAR 2023 + AHA 2025 ACS

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: STEMI in patient with established SLE — premature CAD vs vasculitis vs APS-thrombosis triage; STEMI in young woman (<50) with autoimmune features (malar rash, arthritis, serositis, cytopenias) — de novo SLE consideration; Coronary cath in young SLE patient showing diffuse disease, multivessel involvement, or vasculitic pattern (long stenoses, no discrete plaque) on IVUS/OCT.

Objective

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

Assessment

**STEMI — SLE-associated coronary vasculitis (immune-complex inflammation + premature CAD)** (cardio.stemi.lupus-coronary-vasculitis.v1).
Scope: STEMI in SLE patient with three differential drivers: (1) immune-complex coronary VASCULITIS (this engine — IVUS/OCT shows vessel-wall inflammation, active SLE serology, requires pulse immunosuppression); (2) premature ATHEROSCLEROTIC CAD (route to parent cardio.stemi.core.v1 + secondary prevention); (3) APS THROMBOSIS (route to cardio.stemi.antiphospholipid-syndrome-related.v1 if APS antibodies + thrombus disproportionate to plaque)

No severity triggers fired against current inputs.

Plan

Regimen axis: **SLE coronary vasculitis + STEMI regimen — combines acute reperfusion with pulse immunosuppression and lifelong hydroxychloroquine + secondary prevention; APS overlap drives concurrent warfarin if predominant**.
1. aspirin 162-325 mg chewed load → 81 mg daily lifelong PO daily indefinitely (antiplatelet_cox1, first line) — AHA 2025 ACS Class I + EULAR 2023 (PMID 36750244) — ASA in SLE arterial event; concurrent with warfarin if APS overlap predominant
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo standard DAPT, then reassess given vasculitis status (p2y12_inhibitor, first line) — PLATO PMID 19717846; standard ACS DAPT applies; duration extension if persistent vasculitis activity
3. unfractionated_heparin 70-100 U/kg IV bolus + activated infusion IV bolus + infusion at PCI; transition to oral AC if APS overlap (parenteral_anticoagulant, first line) — AHA 2025 Class I for PCI; UFH preferred over LMWH in APS overlap (anti-Xa more reliable than aPTT if LA prolongs baseline)
4. atorvastatin 80 mg daily lifelong PO daily (statin_high_intensity, first line) — PROVE-IT PMID 15007110; high-intensity statin lifelong post-MI; pleiotropic anti-inflammatory effect particularly relevant for SLE endothelial dysfunction
5. hydroxychloroquine 200-400 mg daily (≤5 mg/kg ideal weight) PO daily lifelong (antimalarial_dmard, first line) — EULAR 2023 (PMID 36750244) Class I — HCQ foundational for ALL SLE patients regardless of activity; cardiovascular benefit (Ruiz-Irastorza 2010 PMID 20132533) — reduces thrombosis + flares + lipid improvement; safe in pregnancy
6. methylprednisolone 1 g IV daily × 3-5 days IV pulse × 3-5 d (corticosteroid_iv_pulse, rescue) — EULAR 2023 — pulse steroids for severe organ-threatening lupus including coronary vasculitis; bridge to oral prednisone + steroid-sparing agent
7. prednisone 1 mg/kg PO daily, taper over months PO daily with taper schedule (corticosteroid_oral, first line) — EULAR 2023 (PMID 36750244) — oral steroid taper after pulse; goal is steroid minimization with steroid-sparing agent
8. cyclophosphamide 500-1000 mg/m² IV monthly × 6 (or low-dose Euro-Lupus 500 mg q2w × 6) IV monthly × 6 (cytotoxic_alkylating, add on) — EULAR 2023 — cyclophosphamide for severe organ-threatening SLE; coronary vasculitis qualifies; gonadotoxic — counseling required
9. mycophenolate_mofetil 1-3 g/d divided BID PO BID (immunosuppressant_imp_dh_inhibitor, second line) — ALMS PMID 19369404 — MMF non-inferior to cyclophosphamide for severe SLE; less gonadotoxic; preferred for women of reproductive age (but teratogenic — switch off before conception)
10. rituximab 1 g IV × 2 doses (days 0 + 14) IV 2 doses (anti_cd20_monoclonal_antibody, rescue) — EULAR 2023 — rituximab off-label for refractory SLE; supported by observational series for organ-threatening disease
11. warfarin 5 mg daily; INR target 2.5-3.5 if APS overlap predominant PO daily lifelong if APS overlap (vitamin_k_antagonist, comorbidity specific) — EULAR 2019 APS Class I; TRAPS PMID 30196097 — warfarin INR 2.5-3.5 lifelong if APS overlap is predominant driver (route to cardio.stemi.antiphospholipid-syndrome-related.v1)
12. carvedilol 3.125 mg BID titrate PO BID (beta_blocker_nonselective, first line) — CAPRICORN PMID 11356436 — post-MI BB benefit; carvedilol preferred for HFrEF GDMT
13. sacubitril-valsartan 24/26 mg BID titrate PO BID (arni, add on) — PIONEER-HF PMID 30403955; ACC/AHA 2022 HF Class I if HFrEF persists post-MI

Setting playbook (outpatient) — Lifelong cardiology + rheumatology multidisciplinary surveillance: serial CTA every 1-2 yr; lifetime triple-therapy management if APS overlap; continued GDMT if HFrEF; aggressive secondary prevention (BP <130/80, lipid LDL <55 per ESC 2019 SLE high-risk, no smoking); pregnancy + family planning counseling (HCQ safe, MMF/cyclophosphamide teratogenic — switch before conception); HCQ retinal screening
14. continue lifelong bundle ASA 81 + warfarin INR 2.5-3.5 (if APS overlap) + atorvastatin 80 + HCQ 400 + GDMT if HFrEF + maintenance immunosuppression per rheumatology PO as scheduled — SLE coronary disease lifelong (EULAR 2023 + AHA 2025 ACS)

Non-pharmacologic actions:
- Pregnancy counseling: HCQ safe in pregnancy (continue throughout); MMF + cyclophosphamide TERATOGENIC — switch to azathioprine ≥3 mo before conception; warfarin teratogenic — switch to LMWH if pregnancy planned + APS overlap
- Lifelong cardiac rehab maintenance + tailored exercise (avoid contact sports if AC)
- Mental health continuity (chronic disease + young adult adjustment)
- Annual influenza + 5-yr pneumococcal vaccinations (avoid live vaccines)
- Sun protection counseling (UV triggers SLE flare)

AVOID / contraindication checks:
- HCQ_baseline_+_annual_eye_exam_for_retinal_toxicity (AAO 2016)
- HCQ_max_dose_5mg_per_kg_ideal_weight (AAO retinal toxicity guideline)
- Cyclophosphamide_gonadotoxicity_counseling_+_fertility_preservation
- MMF_teratogenic_switch_off_before_conception (FDA category D)
- Cyclophosphamide_teratogenic (FDA category D)
- Steroid_taper_must_account_for_adrenal_insufficiency_after_>3wk_use
- Warfarin_target_INR_2.5 3.5_for_arterial_APS_overlap (EULAR 2019)
- Rivaroxaban_AVOID_in_triple_positive_APS_overlap (TRAPS PMID 30196097)
- NEVER_interrupt_AC_without_bridge_in_APS_overlap (interruption = thrombosis trigger)
- Avoid_estrogen_OCP_HRT_in_SLE_+_APS (procoagulant, increases thrombosis + lupus flare risk)
- Live_vaccines_contraindicated_on_immunosuppression

Monitoring

Regimen monitoring:
- echo at 5-7d post event for thrombus screen + lv function
- serial troponin for persistent elevation indicating ongoing vasculitis
- sledai score + complement + dsdna at baseline then q3mo
- CBC LFTs creatinine q2-4 weeks during immunosuppression
- INR q week during warfarin initiation then q month long term if APS overlap
- baseline + annual eye exam on HCQ
- pneumocystis jirovecii prophylaxis during high-dose immunosuppression
- shingrix + pneumococcal vaccinations pre immunosuppression if possible

Setting (outpatient) monitoring:
- Coronary CTA every 1-2 yr
- Annual lipid + BP + INR (if warfarin) + CBC + LFTs + creatinine
- SLEDAI + complement + dsDNA quarterly
- Annual HCQ retinal exam (AAO 2016)

Follow-up plan: Lifelong hydroxychloroquine; immunosuppression taper per rheumatology; aggressive secondary prevention (high-intensity statin, BP control to <130/80, no smoking); cardiology + rheumatology q3-6 mo; surveillance CTA at 1 yr; pregnancy + family planning counseling (HCQ safe in pregnancy, MMF/cyclophosphamide teratogenic — switch before conception)
- Close-out criterion: long-term multidisciplinary plan booked

Monitoring phase: Telemetry; serial troponin (persistent elevation may indicate ongoing vasculitis); daily SLE activity assessment (SLEDAI score, complement trend); steroid taper monitoring (hyperglycemia, infection); echo at 5-7 d for thrombus + LV reassessment; MRI for myocarditis overlap if available

Disposition

Current setting: outpatient — Lifelong cardiology + rheumatology multidisciplinary surveillance: serial CTA every 1-2 yr; lifetime triple-therapy management if APS overlap; continued GDMT if HFrEF; aggressive secondary prevention (BP <130/80, lipid LDL <55 per ESC 2019 SLE high-risk, no smoking); pregnancy + family planning counseling (HCQ safe, MMF/cyclophosphamide teratogenic — switch before conception); HCQ retinal screening

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

Escalation triggers (move to higher acuity):
- New ACS or recurrent CAD on CTA → cardiology + rheumatology — assess vasculitis activity vs atherosclerosis
- EF declining despite GDMT → advanced HF / transplant evaluation
- Bleeding on triple therapy → reassess regimen
- SLE flare → rheumatology — escalate immunosuppression
- Pregnancy planned → switch teratogenic meds 3 mo prior + high-risk obstetrics + cardiology team

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] IVUS/OCT confirms vessel-wall inflammation + active SLE serology (low C3/C4, elevated dsDNA) at index STEMI → pulse steroids + cyclophosphamide/MMF immediately
- [LIFE_THREATENING] Triple-positive APS antibodies + thrombus disproportionate to plaque on IVUS/OCT → APS-driven coronary thrombosis predominant; lifelong warfarin INR 2.5-3.5 vs immunosuppression-only
- [LIFE_THREATENING] Catastrophic APS — multi-organ thrombosis in <1 wk + STEMI + histopathologic small-vessel thrombosis → mortality 50% without aggressive triple therapy

Citations

- 2025 ACC/AHA ACS Guideline + EULAR 2023 SLE management recommendations (Fanouriakis ARD 2023 PMID 36750244) + ACR 2024 SLE management update + AHA cardiovascular risk in autoimmune disease scientific statement [PMID:36750244](https://pubmed.ncbi.nlm.nih.gov/36750244/)
- 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
  • 2025 ACC/AHA ACS Guideline + EULAR 2023 SLE management recommendations (Fanouriakis ARD 2023 PMID 36750244) + ACR 2024 SLE management update + AHA cardiovascular risk in autoimmune disease scientific statement — PMID:36750244
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 38587234) — PMID:38587234
  • Cited evidence (PMID 11907286) — PMID:11907286