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cardio.stemi.prior-mi-recurrent.v1PRODUCTION
cardio.stemi.prior-mi-recurrent.v1

Recurrent STEMI in patient with prior MI history

cardiologyacuteadult
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10/12 authored

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

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Frame

Detailed

Recurrent STEMI in prior-MI patient = treatment-failure ACS; triage culprit mechanism (ISR vs in-stent thrombosis vs new lesion vs graft failure if prior CABG); higher mortality than first MI per SWEDEHEART; route immediately to cardio.stemi.core.v1 for the reperfusion arc with recurrent-MI specialization

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recurrent STEMI in prior-MI patient confirmed

Patient inputs (9)

Recurrent MI patients skew older with cumulative comorbidity burden

Most prior-MI patients on DAPT or single APT; breakthrough ACS on therapeutic regimen → escalate (clopidogrel → ticagrelor, or add platelet function testing)

Contrast nephropathy risk + DOAC dosing

Detailed prior MI + PCI history: dates, vessels intervened, stent type/length, prior cath findings, current antiplatelet regimen — drives culprit-mechanism triage (ISR vs in-stent thrombosis vs new lesion)

Localize culprit territory; compare to prior baseline ECG (Q waves from prior MI may obscure current STEMI in same territory)

Confirms infarction; baseline may be elevated d/t prior MI scar burden

LVEF + RV function + LV thrombus screen; compare to prior echos for cumulative dysfunction trajectory; LV thrombus risk higher (cumulative anterior wall dysfunction)

Hypotension + recurrent STEMI → cardiogenic shock high probability (cumulative LV dysfunction; SCAI 2022)

Mandatory comparison to prior cath films; identify culprit (in-stent restenosis with neointimal hyperplasia vs in-stent thrombosis with thrombotic pattern vs new lesion at separate territory)

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Severity triggers (4)

4 need judgement
  • informationalseverein_stent_restenosis_vs_thrombosis_differential
    Angiography shows lesion at prior stent site; differentiate ISR (smooth tubular narrowing within stent, late presentation, neointimal hyperplasia) vs in-stent thrombosis (acute thrombotic pattern, often LST/VLST per ARC) — strategy diverges (DCB/DES for ISR vs aspiration thrombectomy + IVUS for stent apposition + GP IIb/IIIa for thrombosis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebreakthrough_acs_on_therapeutic_dapt
    Recurrent STEMI in patient confirmed adherent to therapeutic DAPT (ASA + clopidogrel/ticagrelor) — treatment failure; consider platelet function testing or CYP2C19 LOF for clopidogrel patients
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaccumulated_lv_dysfunction_with_thrombus
    Recurrent STEMI patient with cumulative LV dysfunction trajectory (EF declining over multiple events) + new LV thrombus on echo at 5-7 d
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereicd_eligibility_timing_secondary_vs_primary
    Recurrent STEMI complicated by VT/VF → secondary-prevention ICD per AVID (no 40-d wait); OR EF ≤30 at 40-90 d → primary-prevention per MADIT-II
    Trigger could not be auto-evaluated — needs clinician judgement.

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Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Recurrent STEMI phenotype — escalates antiplatelet + adds extended-DAPT (PEGASUS-TIMI 54) + ICD secondary prevention layer to parent cardio.stemi.core.v1 regimen
axis: recurrent_stemi_phenotype
Selected axis "Recurrent STEMI phenotype — escalates antiplatelet + adds extended-DAPT (PEGASUS-TIMI 54) + ICD secondary prevention layer 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: recurrent_stemi_confirmed
    AHA 2025 ACS Class I; lifelong post-MI
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID × 12 mo, then 60 mg BID extended-DAPT per PEGASUS-TIMI 54 • PO • BID × 12 mo standard then BID extended
    triggers: recurrent_stemi_pci_planned, clopidogrel_failure_or_treatment_failure_acs
    PLATO PMID 19717846; PEGASUS-TIMI 54 PMID 25773268 — long-term ticagrelor 60 mg BID reduces MACE in stable post-MI patients with high-risk features (recurrent MI is per-protocol high-risk)
    rxcui 1116632
  • heparin
    first line
    anticoagulant_unfractionated
    70-100 U/kg IV bolus • IV • bolus → infusion per ACT
    triggers: recurrent_stemi_pci_planned
    AHA 2025 Class I peri-PCI anticoagulation
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily indefinitely
    triggers: recurrent_stemi_confirmed
    PROVE-IT PMID 15007110; intensified given recurrent ACS
    rxcui 83367
  • evolocumab
    add on
    pcsk9_inhibitor
    140 mg SC q2w • SC • q2w
    triggers: ldl_above_70_on_max_statin, recurrent_acs_with_persistent_high_ldl
    FOURIER PMID 28304224 — additive LDL reduction + MACE benefit; appropriate for recurrent ACS with persistent elevated LDL on max statin
    rxcui 1665684
  • carvedilol
    first line
    beta_blocker_nonselective
    3.125 mg BID titrate • PO • BID
    triggers: ef_below_40, recurrent_stemi_with_lv_dysfunction
    CAPRICORN PMID 11356436 — post-MI BB benefit; cumulative dysfunction trajectory in recurrent MI
    rxcui 20352
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR 2-3 × 3 mo • PO • daily
    triggers: lv_thrombus_on_echo, cumulative_apical_dysfunction_thrombus_risk
    AHA 2022 Class IIa 3-mo AC for LV thrombus; recurrent MI cohort at higher cumulative risk
    rxcui 11289

outpatient playbook — drug actions (1)

  1. 1. continue intensified secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor 90 BID × 12 mo then 60 BID extended + atorvastatin 80 + PCSK9 if LDL >70 + GDMT • PO/SC • as scheduled
    trigger: post-recurrent-MI
    AHA 2025 + PEGASUS-TIMI 54 + FOURIER

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Patient with documented prior MI presents with new STEMI on ECG; New ST elevation on ECG in patient with prior MI / prior PCI — emergent cath with culprit-mechanism triage; Recurrent ACS in patient already on DAPT or single APT — breakthrough ischemia → escalate antiplatelet + cath.

Objective

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

Assessment

**Recurrent STEMI in patient with prior MI history** (cardio.stemi.prior-mi-recurrent.v1).
Scope: Recurrent STEMI in prior-MI patient = treatment-failure ACS; triage culprit mechanism (ISR vs in-stent thrombosis vs new lesion vs graft failure if prior CABG); higher mortality than first MI per SWEDEHEART; route immediately to cardio.stemi.core.v1 for the reperfusion arc with recurrent-MI specialization

No severity triggers fired against current inputs.

Plan

Regimen axis: **Recurrent STEMI phenotype — escalates antiplatelet + adds extended-DAPT (PEGASUS-TIMI 54) + ICD secondary prevention layer 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
2. ticagrelor 180 mg load → 90 mg BID × 12 mo, then 60 mg BID extended-DAPT per PEGASUS-TIMI 54 PO BID × 12 mo standard then BID extended (p2y12_inhibitor, first line) — PLATO PMID 19717846; PEGASUS-TIMI 54 PMID 25773268 — long-term ticagrelor 60 mg BID reduces MACE in stable post-MI patients with high-risk features (recurrent MI is per-protocol high-risk)
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 given recurrent ACS
5. evolocumab 140 mg SC q2w SC q2w (pcsk9_inhibitor, add on) — FOURIER PMID 28304224 — additive LDL reduction + MACE benefit; appropriate for recurrent ACS with persistent elevated LDL on max statin
6. carvedilol 3.125 mg BID titrate PO BID (beta_blocker_nonselective, first line) — CAPRICORN PMID 11356436 — post-MI BB benefit; cumulative dysfunction trajectory in recurrent MI
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; recurrent MI cohort at higher cumulative risk

Setting playbook (outpatient) — Long-term cardiology + EP surveillance: ICD eligibility decision (secondary or primary prevention), extended-DAPT execution per PEGASUS-TIMI 54 at 12 mo, cardiac rehab completion, intensified secondary prevention maintenance
8. continue intensified secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo then 60 BID extended + atorvastatin 80 + PCSK9 if LDL >70 + GDMT PO/SC as scheduled — post-recurrent-MI (AHA 2025 + PEGASUS-TIMI 54 + FOURIER)

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

AVOID / contraindication checks:
- Ticagrelor_avoid_intracranial_hemorrhage_history (FDA label)
- Warfarin_avoid_active_bleeding (AHA 2022)
- Extended_dapt_caution_high_bleed_risk_patients (PEGASUS exclusions)
- No_routine_thrombolytic_if_pci_capable (ACC/AHA 2025)

Monitoring

Regimen monitoring:
- echo at 5-7d for lv thrombus screen (cumulative dysfunction → higher rate)
- echo at 40d for lvef reassessment for primary prevention icd eligibility (MADIT-II)
- platelet function testing VerifyNow PRU if breakthrough on DAPT (TAILOR-PCI)
- lipid panel at 4-12 weeks for pcsk9 decision if ldl above 70
- EP consult for secondary prevention ICD if VT VF complicated (AVID PMID 9411221)

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

Follow-up plan: Cardiology + EP follow-up; ICD secondary-prevention if VT/VF (no 40-d wait); LVEF re-echo at 40-90 d for primary-prevention ICD eligibility (MADIT-II EF ≤30); long-term ticagrelor 60 mg BID per PEGASUS-TIMI 54 after standard 12 mo DAPT; cardiac rehab; intensified secondary prevention
- Close-out criterion: ICD pathway + extended-DAPT plan + cardiac rehab booked

Monitoring phase: Telemetry; echo at 5-7 d for thrombus + LV function trajectory; daily exam for new murmur; CIN-AKI surveillance

Disposition

Current setting: outpatient — Long-term cardiology + EP surveillance: ICD eligibility decision (secondary or primary prevention), extended-DAPT execution per PEGASUS-TIMI 54 at 12 mo, cardiac rehab completion, intensified secondary prevention maintenance

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
- EF declining despite GDMT → advanced HF eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Angiography shows lesion at prior stent site; differentiate ISR (smooth tubular narrowing within stent, late presentation, neointimal hyperplasia) vs in-stent thrombosis (acute thrombotic pattern, often LST/VLST per ARC) — strategy diverges (DCB/DES for ISR vs aspiration thrombectomy + IVUS for stent apposition + GP IIb/IIIa for thrombosis)
- [SEVERE] Recurrent STEMI in patient confirmed adherent to therapeutic DAPT (ASA + clopidogrel/ticagrelor) — treatment failure; consider platelet function testing or CYP2C19 LOF for clopidogrel patients
- [SEVERE] Recurrent STEMI patient with cumulative LV dysfunction trajectory (EF declining over multiple events) + new LV thrombus on echo at 5-7 d

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + AVID secondary prevention ICD framework + PEGASUS-TIMI 54 extended DAPT [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 9411221) [PMID:9411221](https://pubmed.ncbi.nlm.nih.gov/9411221/)
- Cited evidence (PMID 25773268) [PMID:25773268](https://pubmed.ncbi.nlm.nih.gov/25773268/)
- Cited evidence (PMID 25399658) [PMID:25399658](https://pubmed.ncbi.nlm.nih.gov/25399658/)
- Cited evidence (PMID 32840602) [PMID:32840602](https://pubmed.ncbi.nlm.nih.gov/32840602/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + AVID secondary prevention ICD framework + PEGASUS-TIMI 54 extended DAPT — PMID:37622670
  • Cited evidence (PMID 9411221) — PMID:9411221
  • Cited evidence (PMID 25773268) — PMID:25773268
  • Cited evidence (PMID 25399658) — PMID:25399658
  • Cited evidence (PMID 32840602) — PMID:32840602