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cardio.ascvd.chronic.v1

Chronic coronary / ASCVD secondary prevention

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

5-pillar bundle authored as steps (antiplatelet / lipid / RAS-BB / cardiometabolic / residual-risk+rehab); outpatient + transition setting playbooks; severity triggers including recurrent ACS, LDL ≥55 escalation, residual-inflammatory hsCRP, post-MI-EF-preserved BB reassessment, BP ≥130/80, DM A1c >7, PAD symptoms, ASA intolerance. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template dossier mirroring cardio.htn.core.v1) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (21 verified PMIDs, 23 distinct effect sizes with 95% CI, retrieval-dated 2026-05-16, Consensus→WebSearch/RxNav fallback logged; lipid anchors cross-checked vs just-deepened cardio.lipid.core.v1 bundle); (2) cardio.ascvd.chronic.v1 differentials+ros+finding-lrs seed files (11 differentials w/ cohort-anchored priors — chest-pain/ischaemia partition + residual-risk phenotypes, 14 ROS, 32 LR rows = 16 LR+/16 LR−, 4 conditional-dependency rules incl. Diamond-Forrester composite NOT component-multiplied + hs-troponin|time-since-onset, T_test≈1%/T_treat≈10%); (3) 2nd regimen axis ascvd_residual_risk_phenotype (drug × residual-risk/comorbidity gating as data: residual-cholesterol→PCSK9, residual-inflammatory→colchicine, residual-thrombotic→DPI/extended-DAPT, DM→SGLT2i/GLP-1, statin-intolerant→bempedoic, post-MI-EF-preserved BB-reassessment); (4) RxCUI bugs fixed vs DrugEffectProfile registry: rivaroxaban 1037042→1114195, ezetimibe 38454→341248, evolocumab 1551303→1665684, metoprolol-succ 866427→221124; new agents added with canonical CUIs (prasugrel 613391, alirocumab 1659152, bempedoic 2282403, icosapent 1304974, colchicine 2683, liraglutide 475968 RxNav-verified) — research:rxnav:validate IN:OK/OK/OK for all 18; (5) content refresh to 2023 CCD + 2026 Dyslipidemia: very-high-risk LDL-C <55 & non-HDL-C <85, DPI COMPASS for high-risk, colchicine anti-inflammatory pillar, SGLT2i/GLP-1 in ASCVD±DM, post-MI BB EF-gated per REDUCE-AMI; evidence.pmids 5→22, wrong/mis-scoped POINT+REDUCE+unanchored PEGASUS replaced with verified set; last_reconciled 2026-04-10→2026-05-16; design_brief repointed to co-located path. No engine-specific workup is registered (no `ascvd_followup` adapter); branches into recurrent-presentation workups (chest_pain, acs_pathway) instead — captured indirectly via siblings. PREVENT calculator (replaces Pooled Cohort) is referenced in manifest but not yet a clinical-tools-registry entry — flagged for P0 orphan-calculator sweep (owned by UI-fix terminal, not this depth shard). REBOOT 2025 BB trial not yet PubMed-indexed at retrieval — REDUCE-AMI 2024 used as controlling evidence (bundle §5). DEPTH-PASS-3 2026-05-26 (lane-E): +Cochrane (Taylor CD004816 PMID 23440795) +NMA (Naci CCQO 2013 statin tolerability PMID 23838105 + CTT framing) +USPSTF (Statin B 2022 PMID 35997723 + ASA C/D 2022 PMID 35471505) +ICER (Kazi PCSK9i JAMA 2017 PMID 28829863 ~$450k/QALY original) +2023 ESC ACS (Byrne EHJ-ACVC 2024 PMID 37740496) +decision thresholds (Pauker-Kassirer PMID 7366635 anchor; LDL <55 / non-HDL <85 / PREVENT 7.5/10/20%; REDUCE-AMI BB de-escalation), side-car at cardio.ascvd.chronic.v1._depth-pass-3.md.

Entry points (4)

  • problem_list
    Prior MI / PCI / CABG (ACC/AHA 2022)
    prior_mi
  • problem_list
    Stable angina / chronic coronary syndrome (ACC/AHA 2022)
    stable_angina
  • problem_list
    PAD or carotid disease (ASCVD broader) (ACC/AHA 2022)
    pad_or_carotid
  • problem_list
    Premature CAD family history (risk reclassification) (ACC/AHA 2022)
    family_history_cad

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    PREVENT calculator + drug tolerability (ACC/AHA 2022)
  • sbprequired
    vital • used at CONTEXT
    BP target <130/80 in CCD per 2025 HTN
  • ldlrequired
    lab • used at TREATMENT
    Target <55 very-high risk; <70 high risk per 2026 Lipid
  • creatininerequired
    lab • used at CONTEXT
    Statin/DOAC dosing, COMPASS rivaroxaban renal cutoff (ACC/AHA 2022)
  • a1c
    lab • used at INITIAL_WORKUP
    Glycemic control + SGLT2/GLP-1 in DM-ASCVD (ACC/AHA 2022)
  • lpa
    lab • used at INITIAL_WORKUP
    2026 universal Lp(a) screening Class 1
  • apob
    lab • used at INITIAL_WORKUP
    Non-HDL/ApoB for residual risk (ACC/AHA 2022)
  • recent_acs
    history • used at CONTEXT
    DAPT duration + intensification post-ACS (ACC/AHA 2022)
  • pci_or_cabg
    history • used at CONTEXT
    DAPT timing, antiplatelet agent selection (ACC/AHA 2022)
  • pad
    history • used at CONTEXT
    COMPASS regimen rivaroxaban 2.5 BID + ASA (ACC/AHA 2022)
  • bleed_history
    history • used at RISK_STRATIFICATION
    DAPT bleed risk + extended therapy decision (ACC/AHA 2022)
  • current_meds
    medication • used at CONTEXT
    Existing statin/antiplatelet — escalation vs initiation (ACC/AHA 2022)

12-phase flow (8)

  1. 1FRAME
    Confirm chronic CCD/ASCVD scope; acute chest pain → cardio.stemi.core.v1 (ACC/AHA 2022)
    advance: patient is stable, secondary prevention focus
  2. 2ENTRY
    Capture indication (prior MI/PCI/CABG/CCD/PAD/carotid) + demographics (ACC/AHA 2022)
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    BP, A1c, lipids, current GDMT components, comorbid HF / DM / CKD / PAD (ACC/AHA 2022)
    inputs: sbp, creatinine, current_meds
    advance: context complete
  4. 4INITIAL_WORKUP
    Lipid panel + ApoB + Lp(a) (once), A1c, BMP, ECG; consider CCTA if not on file (ACC/AHA 2022)
    inputs: ldl, a1c, lpa, apob
    actions: panel.lipid, panel.cardiac, panel.renal
    advance: baseline labs documented
  5. 5RISK_STRATIFICATION
    PREVENT (primary) / very-high-risk classification (secondary); HEART/TIMI if recurrent symptoms (ACC/AHA 2022)
    inputs: age, sbp, ldl
    actions: calc.heart
    advance: risk class documented
  6. 6TREATMENT
    High-intensity statin → ezetimibe (Class 1) → PCSK9i / inclisiran / bempedoic acid (cascade); ASA + P2Y12 per CCD/ACS rules; ACEi/ARB; β-blocker if reduced EF / recent MI; SGLT2/GLP-1 in DM; cardiac rehab (ACC/AHA 2022)
    inputs: ldl, sbp, a1c
    advance: all applicable secondary prevention pillars prescribed at goal-tolerated dose
  7. 7MONITORING
    Lipid 4–12 wks post-change then q3–12 mo; LFT/CK with statin only if symptomatic; A1c q3–6 mo; BP at each visit (ACC/AHA 2022)
    inputs: ldl, creatinine
    actions: panel.lipid, panel.renal
    advance: monitoring schedule documented
  8. 8FOLLOWUP
    Cardiac rehab referral, vaccination (flu/pneumococcal/COVID), lifestyle, AAA screening if eligible (ACC/AHA 2022)
    advance: follow-up + adjunctive prevention plan in place