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cardio.stemi.post-cabg-mi.v1PRODUCTION
cardio.stemi.post-cabg-mi.v1

STEMI in prior-CABG patient (graft failure or native progression)

cardiologyacuteadult
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10/12 authored

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

Current phase

Frame

Detailed

Post-CABG STEMI = either graft failure (SVG > LIMA) or native vessel progression at non-grafted territory; advanced CAD substrate → higher CS risk; route immediately to cardio.stemi.core.v1 for the reperfusion arc with post-CABG specialization layer

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STEMI in prior-CABG patient confirmed

Patient inputs (9)

Post-CABG STEMI patients skew older (graft attrition peak 5-10 y); higher contrast/AC bleed risk

Contrast nephropathy risk (multiple cath views needed for graft + native imaging); DOAC dosing; CIN-AKI prevention

Most prior-CABG patients on chronic ASA ± clopidogrel; need to escalate / load fully for ACS

Prior CABG report: which vessels grafted (LIMA-LAD, SVG-RCA, SVG-OM, etc.), date of CABG, prior angiography findings, prior PCIs of grafts — drives culprit-vessel localization + intervention strategy

Localizes culprit territory; may show pseudo-normalisation or atypical pattern given prior infarcts/grafts

Confirms infarction; baseline may be elevated post-CABG patients with chronic ischemia

LVEF + RV function + valvular (post-CABG patients often have valve disease) + LV thrombus screen

Hypotension + post-CABG STEMI → cardiogenic shock high probability (advanced CAD substrate; SCAI 2022)

Mandatory imaging of all grafts (LIMA, SVGs) AND native vessels; identify culprit (graft body stenosis, anastomotic stenosis, native progression at non-grafted territory)

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

Severity triggers (4)

4 need judgement
  • informationallife_threateningsvg_distal_embolization_with_no_reflow
    Intra-procedural distal embolization during SVG-PCI with TIMI flow 0-1 (no-reflow phenomenon) despite patent epicardial vessel
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningredo_cabg_decision_in_shock
    Post-CABG STEMI + SCAI C+ shock + multivessel native disease + multi-graft failure → redo-CABG vs MCS-bridged PCI heart-team decision
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremultivessel_native_disease_pattern_with_failed_grafts
    Angiography shows multivessel native disease (LAD + LCx + RCA territories) with failed grafts — culprit may not be obvious; staged complete revascularization decision
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprior_anti_arrhythmic_toxicity_during_acs
    Post-CABG patient on chronic amiodarone / sotalol presents with STEMI + new arrhythmia or QT prolongation — drug toxicity vs ischemia driven
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Post-CABG STEMI phenotype — adds embolic protection + intensified secondary prevention to parent cardio.stemi.core.v1 regimen
axis: post_cabg_stemi_phenotype
Selected axis "Post-CABG STEMI phenotype — adds embolic protection + intensified secondary prevention to parent cardio.stemi.core.v1 regimen" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed if not already on; continue 81 mg daily • PO • load + 81 mg daily indefinitely
    triggers: post_cabg_stemi_confirmed
    AHA 2025 ACS Class I; lifelong post-MI + post-CABG
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo default DAPT
    triggers: post_cabg_stemi_pci_planned
    PLATO PMID 19717846; preferred over clopidogrel post-MI
    rxcui 1116632
  • heparin
    first line
    anticoagulant_unfractionated
    70-100 U/kg IV bolus • IV • bolus → infusion per ACT
    triggers: post_cabg_stemi_pci_planned
    AHA 2025 Class I peri-PCI anticoagulation
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily indefinitely
    triggers: post_cabg_stemi_confirmed
    PROVE-IT PMID 15007110; intensified post-CABG given graft attrition
    rxcui 83367
  • evolocumab
    add on
    pcsk9_inhibitor
    140 mg SC q2w • SC • q2w
    triggers: ldl_above_70_on_max_statin, post_cabg_recurrent_acs
    FOURIER PMID 28304224 — additive LDL reduction + MACE benefit; appropriate for recurrent ACS in post-CABG patients with elevated LDL
    rxcui 1665684
  • carvedilol
    first line
    beta_blocker_nonselective
    3.125 mg BID titrate • PO • BID
    triggers: ef_below_40, post_cabg_stemi_with_lv_dysfunction
    CAPRICORN PMID 11356436 — post-MI BB benefit
    rxcui 20352
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR 2-3 × 3 mo • PO • daily
    triggers: lv_thrombus_on_echo
    AHA 2022 Class IIa 3-mo AC for LV thrombus
    rxcui 11289

outpatient playbook — drug actions (1)

  1. 1. continue intensified secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + PCSK9 if LDL >70 + GDMT • PO/SC • as scheduled
    trigger: post-CABG-STEMI
    AHA 2025 + FOURIER

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Patient with documented prior CABG presents with new STEMI on ECG; New ST elevation on ECG in patient with prior CABG — emergent cath with graft + native angiography; Recurrent ischemic chest pain in prior-CABG patient + acute ECG change → emergent cath.

Objective

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

Assessment

**STEMI in prior-CABG patient (graft failure or native progression)** (cardio.stemi.post-cabg-mi.v1).
Scope: Post-CABG STEMI = either graft failure (SVG > LIMA) or native vessel progression at non-grafted territory; advanced CAD substrate → higher CS risk; route immediately to cardio.stemi.core.v1 for the reperfusion arc with post-CABG specialization layer

No severity triggers fired against current inputs.

Plan

Regimen axis: **Post-CABG STEMI phenotype — adds embolic protection + intensified secondary prevention to parent cardio.stemi.core.v1 regimen**.
1. aspirin 162-325 mg chewed if not already on; continue 81 mg daily PO load + 81 mg daily indefinitely (antiplatelet_cox1, first line) — AHA 2025 ACS Class I; lifelong post-MI + post-CABG
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo default DAPT (p2y12_inhibitor, first line) — PLATO PMID 19717846; preferred over clopidogrel post-MI
3. heparin 70-100 U/kg IV bolus IV bolus → infusion per ACT (anticoagulant_unfractionated, first line) — AHA 2025 Class I peri-PCI anticoagulation
4. atorvastatin 80 mg PO daily indefinitely (statin_high_intensity, first line) — PROVE-IT PMID 15007110; intensified post-CABG given graft attrition
5. evolocumab 140 mg SC q2w SC q2w (pcsk9_inhibitor, add on) — FOURIER PMID 28304224 — additive LDL reduction + MACE benefit; appropriate for recurrent ACS in post-CABG patients with elevated LDL
6. carvedilol 3.125 mg BID titrate PO BID (beta_blocker_nonselective, first line) — CAPRICORN PMID 11356436 — post-MI BB benefit
7. warfarin 5 mg daily; INR 2-3 × 3 mo PO daily (vitamin_k_antagonist, comorbidity specific) — AHA 2022 Class IIa 3-mo AC for LV thrombus

Setting playbook (outpatient) — Long-term cardiology surveillance: 40-90d LVEF re-echo for ICD eligibility decision; cardiac rehab completion; intensified secondary prevention; staged revasc execution if planned by heart-team
8. continue intensified secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + PCSK9 if LDL >70 + GDMT PO/SC as scheduled — post-CABG-STEMI (AHA 2025 + FOURIER)

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

AVOID / contraindication checks:
- Ticagrelor_avoid_intracranial_hemorrhage_history (FDA label)
- Warfarin_avoid_active_bleeding (AHA 2022)
- Contrast_nephropathy_caution_egfr_below_30 (KDIGO 2020)
- No_routine_thrombolytic_post_cabg_if_pci_capable (ACC/AHA 2025; PCI strongly preferred)

Monitoring

Regimen monitoring:
- echo at 5-7d for lv thrombus screen
- creatinine q24h x 72h for CIN-AKI surveillance (high contrast load)
- echo at 40d for lvef reassessment for icd eligibility (MADIT-II)
- lipid panel at 4-12 weeks for pcsk9 decision if ldl above 70

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

Follow-up plan: Cardiology + heart-team follow-up; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab; intensified secondary prevention; consider redo CABG evaluation if multivessel + recurrent symptoms
- Close-out criterion: ICD/WCD pathway + cardiac rehab + heart-team f/u booked

Monitoring phase: Telemetry; echo at 5-7 d for thrombus + LV function; daily exam for new murmur (mechanical complications still occur); CIN-AKI surveillance d/t high contrast load

Disposition

Current setting: outpatient — Long-term cardiology surveillance: 40-90d LVEF re-echo for ICD eligibility decision; cardiac rehab completion; intensified secondary prevention; staged revasc execution if planned by heart-team

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
- Recurrent ACS → repeat cath + heart-team

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Intra-procedural distal embolization during SVG-PCI with TIMI flow 0-1 (no-reflow phenomenon) despite patent epicardial vessel
- [LIFE_THREATENING] Post-CABG STEMI + SCAI C+ shock + multivessel native disease + multi-graft failure → redo-CABG vs MCS-bridged PCI heart-team decision
- [SEVERE] Angiography shows multivessel native disease (LAD + LCx + RCA territories) with failed grafts — culprit may not be obvious; staged complete revascularization decision

Citations

- 2025 ACC/AHA ACS Guideline (SVG-PCI section) + ESC 2023 ACS + FOURIER PCSK9 + heart-team paradigm [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 21193220) [PMID:21193220](https://pubmed.ncbi.nlm.nih.gov/21193220/)
- Cited evidence (PMID 18316489) [PMID:18316489](https://pubmed.ncbi.nlm.nih.gov/18316489/)
- Cited evidence (PMID 11815441) [PMID:11815441](https://pubmed.ncbi.nlm.nih.gov/11815441/)
- Cited evidence (PMID 3713742) [PMID:3713742](https://pubmed.ncbi.nlm.nih.gov/3713742/)

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