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cardio.stemi.with-mechanical-complication.v1PRODUCTION
cardio.stemi.with-mechanical-complication.v1

STEMI complicated by mechanical complication (PMR / VSR / free-wall rupture)

cardiologyacuteadult
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10/12 authored

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

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Detailed

Mechanical complication of STEMI (PMR / VSR / free-wall rupture) — catastrophic; surgical repair is Class I; medical management alone has >50% mortality for VSR + >80% for free-wall rupture

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Advance when

mechanical complication confirmed on echo

Patient inputs (8)

Older age + female sex + late presentation = higher mechanical complication + surgical mortality (EuroSCORE-II)

eGFR for contrast + dosing; CKD interacts with surgical risk per EuroSCORE-II

STAT TTE/TEE confirms PMR (flail leaflet, eccentric jet), VSR (jet across septum on color Doppler), or free-wall rupture (effusion + tamponade physiology)

Confirms infarct context; trajectory informs reperfusion success

Hypotension typical with mechanical complication; SCAI C-E staging drives MCS escalation

Lactate ≥2 anchors SCAI C+ shock — mechanical complications almost always present in shock

Culprit confirmation; complete coronary anatomy required for CABG planning if surgery indicated

O2 step-up ≥7% from RA→RV = VSR; PA cath also quantifies hemodynamic compromise + guides MCS choice

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningfree_wall_rupture_with_tamponade
    Sudden hemodynamic collapse + new pericardial effusion + tamponade physiology 1-7 d post-MI → free-wall rupture
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpapillary_muscle_rupture_with_acute_severe_mr
    New harsh holosystolic murmur + flash pulmonary edema + flail leaflet on echo → papillary muscle rupture (typically posteromedial in inferior MI from PDA territory)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningventricular_septal_rupture_with_oxygen_step_up
    New harsh holosystolic murmur + hemodynamic deterioration + O2 step-up ≥7% RA→RV at right heart cath OR jet across septum on TEE → VSR
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_with_scai_d_e_shock
    Mechanical complication + SCAI D (deteriorating) or E (extremis) shock — biventricular failure, refractory hypotension despite max vasopressors
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepseudoaneurysm_on_late_echo
    Subacute free-wall rupture contained by pericardium → pseudoaneurysm on echo days-weeks post-MI; high rupture risk
    Trigger could not be auto-evaluated — needs clinician judgement.

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CONTEXTrequiredDrives risk stratification
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Recommended regimen

STEMI mechanical complication overlay — adds MCS bridging + afterload reduction + surgical bridging anticoagulation to parent cardio.stemi.core.v1 reperfusion regimen
axis: stemi_mechanical_complication_overlay
Selected axis "STEMI mechanical complication overlay — adds MCS bridging + afterload reduction + surgical bridging anticoagulation to parent cardio.stemi.core.v1 reperfusion regimen" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed • PO • load + 81 mg daily
    triggers: stemi_with_mechanical_complication
    ACC/AHA 2025 ACS Class I; same as parent — continue through surgery if PCI completed
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID; HOLD if CABG decided pre-load (use cangrelor bridge or no load) • PO • BID
    triggers: stemi_pci_completed_no_immediate_cabg
    PLATO PMID 19717846; same as parent; held if CABG planned within 5-7 d
    rxcui 1116632
  • nitroprusside
    first line
    arterial_venodilator
    0.3 mcg/kg/min titrate to MAP 65-75 • IV • continuous infusion
    triggers: acute_severe_mr_with_adequate_sbp, pmr_bridge_to_or
    Afterload reduction reduces regurgitant fraction in acute severe MR; ESC 2023 ACS expert consensus; only if SBP permits (avoid if SCAI C-E shock without MCS)
    rxcui 7476
  • norepinephrine
    first line
    vasopressor
    0.05-0.5 mcg/kg/min titrate to MAP 65 • IV • continuous infusion
    triggers: cardiogenic_shock_scai_c_or_higher
    SOAP-II PMID 20200382 — first-line vasopressor for cardiogenic shock; bridges to MCS
    rxcui 7512
  • milrinone
    second line
    inotrope_pde3_inhibitor
    0.125-0.5 mcg/kg/min (no bolus in shock) • IV • continuous infusion
    triggers: biventricular_failure_post_mechanical_complication, rv_dysfunction_post_mi
    Inodilator with pulmonary vasodilation — useful for biventricular failure or RV dysfunction; ESC HF 2021
    rxcui 52769

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-mechanical-complication-MI
    AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New harsh holosystolic murmur 2-7 d post-MI ± hemodynamic deterioration → PMR or VSR until proven otherwise; STAT echo: acute severe MR (flail leaflet, eccentric jet, hyperdynamic LV) or VSR jet on color Doppler post-MI; Sudden hemodynamic collapse + new pericardial effusion 1-7 d post-MI → free-wall rupture / pseudoaneurysm / tamponade.

Objective

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

Assessment

**STEMI complicated by mechanical complication (PMR / VSR / free-wall rupture)** (cardio.stemi.with-mechanical-complication.v1).
Scope: Mechanical complication of STEMI (PMR / VSR / free-wall rupture) — catastrophic; surgical repair is Class I; medical management alone has >50% mortality for VSR + >80% for free-wall rupture

No severity triggers fired against current inputs.

Plan

Regimen axis: **STEMI mechanical complication overlay — adds MCS bridging + afterload reduction + surgical bridging anticoagulation to parent cardio.stemi.core.v1 reperfusion regimen**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; same as parent — continue through surgery if PCI completed
2. ticagrelor 180 mg load → 90 mg BID; HOLD if CABG decided pre-load (use cangrelor bridge or no load) PO BID (p2y12_inhibitor, first line) — PLATO PMID 19717846; same as parent; held if CABG planned within 5-7 d
3. nitroprusside 0.3 mcg/kg/min titrate to MAP 65-75 IV continuous infusion (arterial_venodilator, first line) — Afterload reduction reduces regurgitant fraction in acute severe MR; ESC 2023 ACS expert consensus; only if SBP permits (avoid if SCAI C-E shock without MCS)
4. norepinephrine 0.05-0.5 mcg/kg/min titrate to MAP 65 IV continuous infusion (vasopressor, first line) — SOAP-II PMID 20200382 — first-line vasopressor for cardiogenic shock; bridges to MCS
5. milrinone 0.125-0.5 mcg/kg/min (no bolus in shock) IV continuous infusion (inotrope_pde3_inhibitor, second line) — Inodilator with pulmonary vasodilation — useful for biventricular failure or RV dysfunction; ESC HF 2021

Setting playbook (outpatient) — Long-term cardiology + cardiac surgery surveillance: repair durability echo at 30/90/365 d; ICD eligibility decision at 40-90 d if EF <35; cardiac rehab; secondary-prevention bundle
6. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT PO as scheduled — post-mechanical-complication-MI (AHA 2025)

Non-pharmacologic actions:
- ICD/WCD adherence
- Cardiac rehab maintenance phase
- Endocarditis prophylaxis education if prosthetic valve

AVOID / contraindication checks:
- Nitroprusside_avoid_severe_hypotension_or_uncontrolled_shock_without_mcs
- Nitroprusside_cyanide_toxicity_if_prolonged_or_high_dose_or_renal_failure
- Ticagrelor_hold_5 7d_pre_cabg_per_acc_2025
- Milrinone_renal_dose_adjust_egfr_below_30

Monitoring

Regimen monitoring:
- serial echo for repair integrity and residual lesion
- arterial line continuous for titration
- pa cath optional for mcs weaning guidance
- lactate q2-4h during shock
- cyanide thiocyanate levels if nitroprusside >72h or ckd

Setting (outpatient) monitoring:
- Quarterly + annual EF + lipid + INR
- Annual surveillance echo for prosthetic-valve dysfunction

Follow-up plan: Cardiology + cardiac surgery follow-up; echo at 30-90 d for repair durability + LVEF reassessment; ICD eligibility per MADIT-II if EF <30; cardiac rehab
- Close-out criterion: cardiac rehab booked + ICD pathway documented

Monitoring phase: Post-op telemetry + arterial line + PA cath consideration; serial echo for repair integrity; vigilance for residual VSR/MR; antibiotics for prosthetic valve if implanted; anticoagulation per surgical type

Disposition

Current setting: outpatient — Long-term cardiology + cardiac surgery surveillance: repair durability echo at 30/90/365 d; ICD eligibility decision at 40-90 d if EF <35; cardiac rehab; secondary-prevention bundle

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
- Prosthetic dysfunction → cardiac surgery
- New symptoms suggesting recurrent MR/VSR → STAT echo

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Sudden hemodynamic collapse + new pericardial effusion + tamponade physiology 1-7 d post-MI → free-wall rupture
- [LIFE_THREATENING] New harsh holosystolic murmur + flash pulmonary edema + flail leaflet on echo → papillary muscle rupture (typically posteromedial in inferior MI from PDA territory)
- [LIFE_THREATENING] New harsh holosystolic murmur + hemodynamic deterioration + O2 step-up ≥7% RA→RV at right heart cath OR jet across septum on TEE → VSR

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + SCAI 2022 CS staging [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 10460813) [PMID:10460813](https://pubmed.ncbi.nlm.nih.gov/10460813/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)

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