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cardio.stemi.radiation-induced.v1PRODUCTION
cardio.stemi.radiation-induced.v1

Radiation-induced STEMI (post chest/mediastinal XRT)

cardiologyacuteadult
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Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

Radiation-induced STEMI = chest XRT survivor presenting with ostial-pattern ACS; route to cardio.stemi.core.v1 reperfusion arc but flag ostial-disease workflow + IVUS-mandatory + multidisciplinary cardio-onc consult

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Advance rule
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Advance when

STEMI confirmed + radiation history elicited

Patient inputs (9)

Radiation-induced STEMI presents 1-2 decades earlier than de novo ASCVD; young age + chest-XRT history is the diagnostic signature

Dose >30 Gy + mantle/mediastinal field + interval ≥5 yr defines high-risk radiation-CAD substrate (Heidenreich PMID 17891999)

Active malignancy alters AC/DAPT bleed risk + may preclude long-term DAPT; current oncology status determines bundle aggressiveness

Contrast nephropathy risk + DOAC dosing; cancer patients often have baseline AKI from chemo or contrast load

Standard STEMI criteria; ostial LAD radiation-CAD often gives anterior STEMI pattern; check for conduction disease (radiation-related fibrosis)

Standard ACS biomarker; in radiation-induced microvascular disease may be modestly elevated even without obstructive CAD

Concomitant radiation valvulopathy (calcific AS, MR) + constrictive pericarditis screening — mandatory in radiation survivors

Hypotension in radiation-induced STEMI may also reflect concurrent constrictive/restrictive radiation pericardial injury, not pure cardiogenic shock

IVUS/OCT MANDATORY for ostial radiation-CAD assessment — coronary CTA underestimates ostial stenosis severity due to motion + calcium artefact (ESC cardio-onc 2022 PMID 36017575)

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Severity triggers (5)

5 need judgement
  • informationallife_threateningradiation_pericardial_constriction_decompensation
    Echo or hemodynamics show constrictive physiology contributing to shock or HF post-MI in radiation survivor
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereostial_radiation_cad_not_pci_amenable
    IVUS/OCT shows severe ostial calcification + lesion morphology not amenable to PCI even with intravascular lithotripsy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecabg_decision_in_irradiated_mediastinum
    CABG considered in patient with prior chest XRT — markedly elevated operative mortality + sternal wound complication rate due to radiation fibrosis + chest-wall lymphedema
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconcurrent_secondary_malignancy_in_radiation_field
    Workup reveals secondary malignancy (radiation-induced sarcoma, breast cancer post-Hodgkin XRT) in radiation field during ACS admission
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechest_wall_lymphedema_complicating_access
    Chest-wall or upper-extremity lymphedema (typically post-breast-cancer XRT + axillary node dissection) complicating arterial access for cath
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Radiation-induced STEMI phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen with cardio-onc-specific secondary prevention
axis: radiation_induced_stemi_phenotype
Selected axis "Radiation-induced STEMI phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen with cardio-onc-specific secondary prevention" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed • PO • load + 81 mg daily
    triggers: stemi_radiation_induced
    ACC/AHA 2025 ACS Class I; same as parent
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo default DAPT
    triggers: stemi_pci_planned
    PLATO PMID 19717846; same as parent — but consider shorter DAPT if active cancer + bleed risk per ESC cardio-onc 2022
    rxcui 1116632
  • atorvastatin
    first line
    hmg_coa_reductase_inhibitor
    80 mg PO daily • PO • daily
    triggers: stemi_post_pci, radiation_cad_secondary_prevention
    High-intensity statin essential — radiation-CAD has accelerated trajectory; PROVE-IT extrapolation; ESC cardio-onc 2022 PMID 36017575
    rxcui 83367
  • lisinopril
    first line
    acei
    5 mg PO daily, titrate to 20-40 mg • PO • daily
    triggers: lvef_below_40, radiation_cardiomyopathy_overlap
    ACEi for LV remodeling + concurrent radiation cardiomyopathy substrate; AHA cardio-onc 2022
    rxcui 29046
  • heparin
    first line
    anticoagulant_unfractionated
    70-100 U/kg IV bolus • IV • bolus + infusion
    triggers: stemi_pci_planned
    AHA 2025 Class I; same as parent
    rxcui 5224
  • carvedilol
    add on
    beta_blocker_alpha_beta
    3.125 mg BID titrate • PO • BID
    triggers: lvef_below_40, post_radiation_cardiomyopathy
    CAPRICORN PMID 11356436; beta-blocker indicated for any radiation-related LV dysfunction
    rxcui 20352

outpatient playbook — drug actions (1)

  1. 1. continue secondary-prevention bundle
    rxcui 243670
    ASA 81 + statin + ACEi + BB if EF <40 • PO • as scheduled
    trigger: post-radiation-induced-STEMI
    ESC cardio-onc 2022

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Prior mediastinal/chest XRT ≥5 years (Hodgkin lymphoma, breast, lung, esophageal cancer) → consider radiation-induced CAD as STEMI etiology; ST-elevation MI ECG in cancer survivor with prior chest XRT — likely ostial coronary disease; Atypical/typical angina in patient <55 with prior Hodgkin XRT — high pretest probability of accelerated ostial CAD.

Objective

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

Assessment

**Radiation-induced STEMI (post chest/mediastinal XRT)** (cardio.stemi.radiation-induced.v1).
Scope: Radiation-induced STEMI = chest XRT survivor presenting with ostial-pattern ACS; route to cardio.stemi.core.v1 reperfusion arc but flag ostial-disease workflow + IVUS-mandatory + multidisciplinary cardio-onc consult

No severity triggers fired against current inputs.

Plan

Regimen axis: **Radiation-induced STEMI phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen with cardio-onc-specific secondary prevention**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; same as parent
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo default DAPT (p2y12_inhibitor, first line) — PLATO PMID 19717846; same as parent — but consider shorter DAPT if active cancer + bleed risk per ESC cardio-onc 2022
3. atorvastatin 80 mg PO daily PO daily (hmg_coa_reductase_inhibitor, first line) — High-intensity statin essential — radiation-CAD has accelerated trajectory; PROVE-IT extrapolation; ESC cardio-onc 2022 PMID 36017575
4. lisinopril 5 mg PO daily, titrate to 20-40 mg PO daily (acei, first line) — ACEi for LV remodeling + concurrent radiation cardiomyopathy substrate; AHA cardio-onc 2022
5. heparin 70-100 U/kg IV bolus IV bolus + infusion (anticoagulant_unfractionated, first line) — AHA 2025 Class I; same as parent
6. carvedilol 3.125 mg BID titrate PO BID (beta_blocker_alpha_beta, add on) — CAPRICORN PMID 11356436; beta-blocker indicated for any radiation-related LV dysfunction

Setting playbook (outpatient) — Long-term cardio-oncology surveillance: serial echo q12mo for radiation valvulopathy progression, annual lipid + LDL <55 target, repeat CTA at 5yr post-PCI for disease progression, secondary cancer screening
7. continue secondary-prevention bundle ASA 81 + statin + ACEi + BB if EF <40 PO as scheduled — post-radiation-induced-STEMI (ESC cardio-onc 2022)

Non-pharmacologic actions:
- Smoking cessation maintenance
- Cardiac rehab maintenance phase
- Annual cardio-onc clinic

AVOID / contraindication checks:
- Dapt_caution_active_thrombocytopenia_from_recent_chemo (ESC cardio onc 2022)
- Cabg_high_mortality_in_irradiated_mediastinum_chest_wall_lymphedema (Heidenreich 2010)
- Contrast_minimize_in_post_chemo_aki (KDIGO 2021)
- Radial_access_preferred_femoral_lymphedema_in_breast_xrt_survivors

Monitoring

Regimen monitoring:
- echo q12mo for radiation valvulopathy progression
- lipid panel q6mo high intensity statin target ldl below 55
- cardio onc clinic dual followup
- consider cta at 5yr post pci for disease progression

Setting (outpatient) monitoring:
- Annual echo + lipid + cardio-onc clinic

Follow-up plan: Cardiology + cardio-oncology dual follow-up; serial echo q12mo for radiation valvulopathy; high-intensity secondary prevention; smoking cessation paramount; consider repeat CTA at 5yr post-PCI
- Close-out criterion: cardio-onc longitudinal plan booked

Monitoring phase: Telemetry; daily exam for new murmur (radiation valvulopathy progression); echo at 24-48h to reassess pericardial physiology; renal function trending (cancer + contrast)

Disposition

Current setting: outpatient — Long-term cardio-oncology surveillance: serial echo q12mo for radiation valvulopathy progression, annual lipid + LDL <55 target, repeat CTA at 5yr post-PCI for disease progression, secondary cancer screening

Disposition criteria:
- Long-term continuation; cross-link to cardio.ascvd.chronic.v1 + cardio-onc longitudinal program

Escalation triggers (move to higher acuity):
- Recurrent angina → return to cath — radiation-CAD has high restenosis + de-novo disease rate
- New AS murmur → echo + AVR consideration (TAVR preferred over SAVR in irradiated field)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Echo or hemodynamics show constrictive physiology contributing to shock or HF post-MI in radiation survivor
- [SEVERE] IVUS/OCT shows severe ostial calcification + lesion morphology not amenable to PCI even with intravascular lithotripsy
- [SEVERE] CABG considered in patient with prior chest XRT — markedly elevated operative mortality + sternal wound complication rate due to radiation fibrosis + chest-wall lymphedema

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2022 Cardio-Oncology Guideline (Lyon PMID 36017575) + AHA Scientific Statement Cardio-Oncology 2022 [PMID:36017575](https://pubmed.ncbi.nlm.nih.gov/36017575/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 17891999) [PMID:17891999](https://pubmed.ncbi.nlm.nih.gov/17891999/)
- Cited evidence (PMID 17893376) [PMID:17893376](https://pubmed.ncbi.nlm.nih.gov/17893376/)
- Cited evidence (PMID 23484825) [PMID:23484825](https://pubmed.ncbi.nlm.nih.gov/23484825/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2025 ACC/AHA ACS Guideline + ESC 2022 Cardio-Oncology Guideline (Lyon PMID 36017575) + AHA Scientific Statement Cardio-Oncology 2022 — PMID:36017575
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 17891999) — PMID:17891999
  • Cited evidence (PMID 17893376) — PMID:17893376
  • Cited evidence (PMID 23484825) — PMID:23484825