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cardio.stemi.with-out-of-hospital-arrest.v1PRODUCTION
cardio.stemi.with-out-of-hospital-arrest.v1

STEMI complicated by out-of-hospital cardiac arrest with ROSC

cardiologyacuteadult
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10/12 authored

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

Current phase

Frame

Detailed

Composite engine: post-ROSC + STEMI on first ECG → CONCURRENT cath PCI within 90 min + TTM 33-37.5 °C × 24 h; reperfusion arc routes to cardio.stemi.core.v1; post-arrest arc routes to cardio.post-arrest.core.v1; both run in parallel

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Advance rule
Set
Advance when

composite criteria met (post-ROSC + STEMI ECG)

Patient inputs (16)

Age + frailty drive prognostic discussion + ICD eligibility post-recovery (MADIT-II PMID 11907286)

Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020; CAHP/OHCA scores)

Shockable (VF/pVT) → cardiac etiology > 80%; STEMI ECG confirms culprit; emergent cath per AHA 2020 Class I

CPR duration → prognostic + ECPR eligibility (ARREST <60 min low-flow); informs neuroprognostication

AKI common post-arrest; contrast nephropathy risk; DOAC dosing post-DAPT transition

Arrhythmogenic; goal K 4-4.5 to suppress recurrent VT/VF; correct aggressively (AHA 2020 Class I)

STEMI on first post-ROSC ECG → emergent cath within 90 min (AHA 2020 Class I)

Confirms infarct + serial trending; peak proportional to infarct size + outcomes

Hypoperfusion marker; trajectory predicts SCAI staging + neurologic recovery

LV function + RV strain + valvular cause + tamponade exclusion; drives MCS decision

Post-ROSC MAP ≥65 target; persistent hypotension after fluid + pressor → SCAI C+ shock + Impella per DanGer Shock

TTM target 33-37.5 °C × 24 h (TTM2 PMID 34133859); start cooling within 6 h of ROSC; rewarm 0.25-0.5 °C/h

Avoid hyperoxia post-ROSC: SpO2 92-98% (AHA 2020 Class IIa); brain injury from FiO2 100%

Confirm STEMI culprit + lesion location; complete revasc decision per COMPLETE PMID 31475795

Exclude ICH or alternate cause of arrest if any concern (head trauma, focal exam); does NOT delay cath if STEMI on ECG

Neuroprognostication marker at 48-72 h post-ROSC per Sandroni ERC-ESICM 2021; >60 µg/L poor prognosis when combined with other modalities

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

Severity triggers (4)

4 need judgement
  • informationallife_threateningstemi_ohca_with_cardiogenic_shock_scai_c_plus
    STEMI + post-ROSC + SBP <90 + lactate ≥2 + end-organ dysfunction → SCAI C+ shock; subgroup with greatest MCS benefit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_vt_vf_post_pci_during_ttm
    Recurrent VT/VF post-PCI during TTM despite reperfusion + sedation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmultimodal_poor_neuro_prognosis_at_72h
    Multimodal poor prognosis at ≥72 h post-rewarming per Sandroni ERC-ESICM 2021 (absent pupillary + corneal reflexes + bilateral absent SSEPs + NSE >60 µg/L + malignant EEG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningin_stent_restenosis_or_re_occlusion
    Recurrent ST elevation or hemodynamic instability post-PCI suggesting stent thrombosis or re-occlusion
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

STEMI + OHCA composite — concurrent reperfusion bundle + TTM sedation + MAP support + recurrent-VT prophylaxis
axis: stemi_ohca_composite_overlay
Selected axis "STEMI + OHCA composite — concurrent reperfusion bundle + TTM sedation + MAP support + recurrent-VT prophylaxis" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg PR or via NG tube (patient comatose post-ROSC) • PR/NG • load + 81 mg daily
    triggers: stemi_post_rosc
    AHA 2025 ACS Class I; PR/NG route given comatose state; same as parent STEMI
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg crushed via NG tube; 90 mg BID maintenance • NG → PO • BID × 12 mo DAPT
    triggers: stemi_pci_planned_post_rosc
    PLATO PMID 19717846; crushed administration via NG during TTM has reduced absorption — consider cangrelor IV bridge for high-risk anatomy or shock
    rxcui 1116632
  • unfractionated_heparin
    first line
    heparin_anticoagulant
    70-100 U/kg IV bolus + cath-lab maintenance per ACT • IV • bolus + infusion
    triggers: stemi_pci_planned
    AHA 2025 Class I; standard cath-lab AC
    rxcui 5224
  • atorvastatin
    first line
    statin
    80 mg via NG tube • NG → PO • daily
    triggers: stemi_confirmed
    PROVE-IT PMID 15007110; high-intensity statin
    rxcui 83367
  • propofol
    first line
    sedative_gaba_agonist
    25-75 mcg/kg/min infusion (intubated, sedated for TTM) • IV • continuous infusion
    triggers: ttm_active, comatose_post_rosc
    Sedation during TTM; rapid titration; consider midazolam alternative if hypotension
    rxcui 8782
  • fentanyl
    first line
    opioid_analgesic
    25-100 mcg/h infusion • IV • continuous infusion
    triggers: ttm_active, shivering_or_pain
    Analgesia during TTM; reduces shivering threshold
    rxcui 4337
  • norepinephrine
    first line
    alpha_beta_agonist_vasopressor
    0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 • IV • continuous infusion
    triggers: post_rosc_hypotension_map_lt_65, cardiogenic_shock_scai_c
    SOAP-II PMID 20200382 — norepinephrine first-line; AHA 2020 Class IIa MAP ≥65 target
    rxcui 7508
  • dobutamine
    add on
    beta1_agonist_inotrope
    2.5-10 mcg/kg/min IV titrate • IV • continuous infusion
    triggers: post_pci_low_cardiac_output_with_adequate_map
    Inotropic support post-PCI when low CO drives shock; AHA 2020
    rxcui 3616
  • amiodarone
    comorbidity specific
    antiarrhythmic_class_iii
    150 mg IV bolus → 1 mg/min × 6 h → 0.5 mg/min • IV • continuous infusion × 24 h
    triggers: recurrent_vt_vf_post_pci, electrical_storm
    AHA 2020 ACLS Class IIb; recurrent VT/VF post-reperfusion common; AHA 2017 VA management
    rxcui 203114
  • magnesium_sulfate
    first line
    electrolyte_repletion
    2 g IV bolus; repeat × 1 if Mg <2 • IV • bolus
    triggers: post_arrest_low_or_borderline_mg
    Goal Mg ≥2 to suppress arrhythmia; intracellular Mg often depleted post-arrest
    rxcui 6585
  • cisatracurium
    rescue
    neuromuscular_blocker
    0.15 mg/kg IV bolus then 0.5-2 mcg/kg/min infusion • IV • continuous infusion
    triggers: shivering_during_ttm_unresponsive_to_sedation_plus_skin_counterwarming
    NMB to break shivering during TTM only when sedation + counter-warming inadequate; mask seizures so EEG monitoring required
    rxcui 136561

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-STEMI-OHCA
    AHA 2025 ACS

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: STEMI on first post-ROSC 12-lead ECG → emergent cath within 90 min + TTM concurrent (AHA 2020 Class I); Comatose ROSC + STEMI ECG → CONCURRENT cath PCI + TTM 33-37.5 °C × 24 h (TTM2); Witnessed shockable arrest + ROSC + STEMI on subsequent ECG — composite engine activates.

Objective

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

Assessment

**STEMI complicated by out-of-hospital cardiac arrest with ROSC** (cardio.stemi.with-out-of-hospital-arrest.v1).
Scope: Composite engine: post-ROSC + STEMI on first ECG → CONCURRENT cath PCI within 90 min + TTM 33-37.5 °C × 24 h; reperfusion arc routes to cardio.stemi.core.v1; post-arrest arc routes to cardio.post-arrest.core.v1; both run in parallel

No severity triggers fired against current inputs.

Plan

Regimen axis: **STEMI + OHCA composite — concurrent reperfusion bundle + TTM sedation + MAP support + recurrent-VT prophylaxis**.
1. aspirin 162-325 mg PR or via NG tube (patient comatose post-ROSC) PR/NG load + 81 mg daily (antiplatelet_cox1, first line) — AHA 2025 ACS Class I; PR/NG route given comatose state; same as parent STEMI
2. ticagrelor 180 mg crushed via NG tube; 90 mg BID maintenance NG → PO BID × 12 mo DAPT (p2y12_inhibitor, first line) — PLATO PMID 19717846; crushed administration via NG during TTM has reduced absorption — consider cangrelor IV bridge for high-risk anatomy or shock
3. unfractionated_heparin 70-100 U/kg IV bolus + cath-lab maintenance per ACT IV bolus + infusion (heparin_anticoagulant, first line) — AHA 2025 Class I; standard cath-lab AC
4. atorvastatin 80 mg via NG tube NG → PO daily (statin, first line) — PROVE-IT PMID 15007110; high-intensity statin
5. propofol 25-75 mcg/kg/min infusion (intubated, sedated for TTM) IV continuous infusion (sedative_gaba_agonist, first line) — Sedation during TTM; rapid titration; consider midazolam alternative if hypotension
6. fentanyl 25-100 mcg/h infusion IV continuous infusion (opioid_analgesic, first line) — Analgesia during TTM; reduces shivering threshold
7. norepinephrine 0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 IV continuous infusion (alpha_beta_agonist_vasopressor, first line) — SOAP-II PMID 20200382 — norepinephrine first-line; AHA 2020 Class IIa MAP ≥65 target
8. dobutamine 2.5-10 mcg/kg/min IV titrate IV continuous infusion (beta1_agonist_inotrope, add on) — Inotropic support post-PCI when low CO drives shock; AHA 2020
9. amiodarone 150 mg IV bolus → 1 mg/min × 6 h → 0.5 mg/min IV continuous infusion × 24 h (antiarrhythmic_class_iii, comorbidity specific) — AHA 2020 ACLS Class IIb; recurrent VT/VF post-reperfusion common; AHA 2017 VA management
10. magnesium_sulfate 2 g IV bolus; repeat × 1 if Mg <2 IV bolus (electrolyte_repletion, first line) — Goal Mg ≥2 to suppress arrhythmia; intracellular Mg often depleted post-arrest
11. cisatracurium 0.15 mg/kg IV bolus then 0.5-2 mcg/kg/min infusion IV continuous infusion (neuromuscular_blocker, rescue) — NMB to break shivering during TTM only when sedation + counter-warming inadequate; mask seizures so EEG monitoring required

Setting playbook (outpatient) — Long-term cardiology + EP + neurology surveillance: ICD interrogation, GDMT maintenance, cardiac rehab completion, secondary prevention, mental health, cognitive rehab if anoxic injury
12. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT PO as scheduled — post-STEMI-OHCA (AHA 2025 ACS)

Non-pharmacologic actions:
- ICD interrogation per device protocol
- Cardiac rehab maintenance phase
- Driving restriction per state law (often 6 mo after VF/VT arrest)
- Cognitive rehab if anoxic injury
- PTSD therapy if post-arrest anxiety

AVOID / contraindication checks:
- Propofol_avoid_severe_hypotension_or_egg_soy_allergy
- Nmb_with_continuous_eeg_monitoring_due_to_seizure_masking
- Ticagrelor_reduced_absorption_during_ttm_consider_cangrelor_iv_bridge
- Amiodarone_avoid_severe_qt_prolongation
- Fentanyl_dose_reduce_severe_renal_or_hepatic_failure
- Dobutamine_avoid_severe_tachyarrhythmia

Monitoring

Regimen monitoring:
- continuous arterial line + telemetry + temp
- serial k mg q6h to keep k 4-4.5 mg 2
- troponin trend q6h x 3
- lactate trend q4h
- eeg continuous during ttm for seizure screen especially with nmb
- echo at 24h for lv recovery + at 5-7d for lv thrombus
- nse at 48h + 72h for neuroprognostication

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

Follow-up plan: Multimodal neuroprognostication ≥72 h post-rewarming per Sandroni ERC-ESICM 2021 (clinical exam + EEG + SSEP + NSE + neuroimaging); ICD secondary-prevention per AVID once acute reversible cause addressed (any sustained VT/VF arrest in setting of STEMI usually qualifies); cardiology + EP + neurology follow-up; cardiac rehab; mental health (PTSD/anoxic injury cognitive screening)
- Close-out criterion: neuroprognostication complete + ICD pathway documented + multidisciplinary follow-up booked

Monitoring phase: Continuous telemetry + arterial line + temperature monitoring; serial K + Mg q6 h; troponin trend; daily exam off sedation if possible; daily echo for LV recovery; consider EEG for non-convulsive seizure (post-arrest 10-20% incidence)

Disposition

Current setting: outpatient — Long-term cardiology + EP + neurology surveillance: ICD interrogation, GDMT maintenance, cardiac rehab completion, secondary prevention, mental health, cognitive rehab if anoxic injury

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists; cardio.ascvd.chronic.v1 for secondary prevention

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- Recurrent CAD symptoms → ischemia eval
- Cognitive decline → neurology + cognitive rehab

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] STEMI + post-ROSC + SBP <90 + lactate ≥2 + end-organ dysfunction → SCAI C+ shock; subgroup with greatest MCS benefit
- [LIFE_THREATENING] Recurrent VT/VF post-PCI during TTM despite reperfusion + sedation
- [LIFE_THREATENING] Multimodal poor prognosis at ≥72 h post-rewarming per Sandroni ERC-ESICM 2021 (absent pupillary + corneal reflexes + bilateral absent SSEPs + NSE >60 µg/L + malignant EEG)

Citations

- 2025 ACC/AHA ACS Guideline + AHA 2020 ACLS / Post-Cardiac-Arrest Care + ERC-ESICM 2021 Post-Resuscitation [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 24237006) [PMID:24237006](https://pubmed.ncbi.nlm.nih.gov/24237006/)
- Cited evidence (PMID 31532382) [PMID:31532382](https://pubmed.ncbi.nlm.nih.gov/31532382/)

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