Final Diagnosis for STEMI with Successful Revascularization
The final diagnosis should be: "Acute ST-Elevation Myocardial Infarction (STEMI) of the anteroseptal wall, status post successful primary percutaneous coronary intervention with drug-eluting stent placement to proximal-to-mid left anterior descending artery."
Essential Diagnostic Components
Primary Diagnosis Elements
Specify "Acute STEMI" rather than just "myocardial infarction" to indicate the ST-elevation presentation and acute nature of the event 1
Include anatomic location "anteroseptal wall" as this reflects the ECG territory and myocardial region affected by the LAD occlusion 1
Document "status post primary PCI" to indicate the reperfusion strategy employed, which is the Class I recommended treatment for STEMI within 12 hours of symptom onset 1
Procedural Details to Include
Specify stent type - if drug-eluting stent (DES) was used, this should be documented as it requires 12 months of dual antiplatelet therapy per guidelines 1
Document vessel and location - "proximal-to-mid LAD" identifies the culprit vessel and specific segment treated, which has prognostic implications 1, 2
Note "successful revascularization" if TIMI 3 flow was achieved, as this is the procedural goal and affects prognosis 1, 3
Additional Diagnostic Considerations
Complications or High-Risk Features
If cardiogenic shock was present, add "complicated by cardiogenic shock" as this dramatically changes prognosis and management 1
If left ventricular dysfunction was documented, include "with reduced ejection fraction" and the specific percentage 1
Document any mechanical complications such as ventricular septal defect or mitral regurgitation if present 1
Coronary Anatomy Beyond Culprit Lesion
Note multivessel disease if present - if angiography revealed significant stenoses in other vessels, document as "with multivessel coronary artery disease" since this affects long-term management and may require staged revascularization 1
The LAD location carries independent higher restenosis risk (OR 3.0) and warrants closer follow-up 2
Complete Diagnosis Format Example
"Acute ST-Elevation Myocardial Infarction of the anteroseptal wall, status post successful primary percutaneous coronary intervention with drug-eluting stent placement to proximal-to-mid left anterior descending artery, with TIMI 3 flow restoration"
Add if Applicable:
- "with preserved left ventricular ejection fraction" or "with reduced LVEF (specify %)" 1
- "complicated by [cardiogenic shock/ventricular arrhythmias/heart failure]" 1
- "with multivessel coronary artery disease" if non-culprit lesions ≥50% stenosis were identified 1
Critical Documentation Elements
Time metrics - door-to-balloon time should be documented separately in the procedure note as quality metric (goal <90 minutes for PCI-capable hospitals) 1
Post-procedure antiplatelet regimen - aspirin plus P2Y12 inhibitor (prasugrel, ticagrelor, or clopidogrel) for 12 months is mandatory with DES 1
Risk stratification - proximal LAD involvement indicates higher-risk anatomy requiring aggressive secondary prevention 1, 2