12-phase flow (12)

1. 1FRAME
   Confirm NSTE-ACS in active-cancer patient — key first decisions: (1) type-1 vs type-2 NSTEMI? (2) ICI myocarditis differential? (3) bleeding-risk burden (CIT, tumor anatomy, recent bleed)? (4) prognosis estimate from oncology? Inherit core NSTEMI workflow via routing, modify per cancer-specific axes
   inputs: ecg_serial, hs_troponin_serial
   advance: NSTEMI confirmed + cancer context characterized + ICI myocarditis ruled in/out
2. 2ENTRY
   Triage chest pain pathway with serial ECG + 0/1-h hsTn + cardio-oncology consult activated; ASA load (162–325 mg) usually safe even with mild thrombocytopenia >50K but verify platelet count first
   inputs: age
   advance: pathway started + cardio-onc consult requested
3. 3CONTEXT
   Cancer type + stage + treatment + prognosis estimate; recent bleeding; CIT trajectory; specific cardiotoxic agent exposure; ICI exposure window (myocarditis usually within 30–60 d of initiation); prior CAD; mental health + family + GOC discussion
   inputs: cancer_type_and_stage, cancer_treatment_active_or_recent, prognosis_estimate_with_oncologist, recent_bleeding_history, sbp, hr, creatinine_egfr, prior_cad_pci_cabg
   advance: context complete + cardio-onc + oncology + palliative care consults engaged as appropriate
4. 4RED_FLAGS
   Hemodynamic instability; refractory ischemia despite medical therapy with reasonable prognosis → invasive consideration; mechanical complication; severe thrombocytopenia <30K precluding any antithrombotic; active hemorrhage from tumor; ICI myocarditis with conduction disease / pump dysfunction → high-dose steroids urgently
   inputs: sbp, cbc_with_diff
   actions: cardiogenic_shock, acs_pathway
   advance: red flags screened + escalations triggered
5. 5INITIAL_WORKUP
   Serial ECG + 0/1-h hsTn + CBC with diff + coag with fibrinogen + BMP + LFTs + lipids + CXR + bedside echo + cardiac MRI if ICI myocarditis suspicion; type-and-screen if cath possibility; reconcile current cancer treatment regimen with cardiology team
   inputs: ecg_serial, hs_troponin_serial, cbc_with_diff, coag_with_fibrinogen, creatinine_egfr, lfts, cxr, tte_bedside
   actions: acs_pathway, panel.cardiac, panel.renal
   advance: workup complete + type-1 vs type-2 differentiated + ICI myocarditis screened
6. 6BRANCHING_WORKUP
   Cardiac MRI for ICI myocarditis (LGE, edema); endomyocardial biopsy if MRI inconclusive; type-2 NSTEMI → identify + correct trigger (transfuse anemia, treat infection, hydration, oxygenation); type-1 NSTEMI → cath strategy decision per shared-decision framework
   inputs: cardiac_mri_if_ici_suspected
   advance: mechanism confirmed + cath decision made or trigger correction in progress
7. 7DIFFERENTIAL
   Type-1 plaque-rupture NSTEMI (standard ACS regimen modified) vs type-2 demand-mismatch NSTEMI (correct trigger primarily) vs ICI myocarditis (steroids) vs 5-FU/capecitabine vasospasm (CCB + discontinue agent) vs radiation coronary disease (often distal LAD/LM ostia, diffuse pattern) vs anthracycline cardiomyopathy with secondary ischemia vs paraneoplastic / coagulopathy-driven vs pericarditis from radiation/mets
   advance: mechanism + cancer-specific etiology established
8. 8RISK_STRATIFICATION
   HEART / TIMI / GRACE band-mapped (interpret cautiously — cancer not in scoring systems, often underestimates risk); HAS-BLED for bleeding risk (every cancer patient is high-bleed-risk by SCAI 2019 consensus); KCCQ for HF status; cardio-oncology framework integration
   inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial, cbc_with_diff
   actions: calc.heart, calc.timi_nstemi, calc.has_bled, calc.ckd_epi_2021
   advance: risk band documented + bleeding-risk consensus statement applied
9. 9TREATMENT
   ASA 81 mg daily continued unless platelets <30K or active bleeding; if PCI performed: P2Y12 (ticagrelor or clopidogrel; AVOID prasugrel + ticagrelor if active intracranial mass or recent bleed) + UFH parenteral × 24h; DAPT shortened to 3–6 mo per MASTER DAPT philosophy + ESC cardio-onc 2022 §6.4; statin 80 mg continued (multiple cardio-onc registries show benefit + low toxicity); BB per EF + chemo continuation; cath only with shared decision (prognosis + values + feasibility); type-2 NSTEMI primary management is TRIGGER CORRECTION (transfuse anemia, treat infection, hydrate, oxygenate); ICI myocarditis = methylprednisolone 1–2 mg/kg/d ± additional immunosuppression
   inputs: cbc_with_diff, creatinine_egfr
   actions: acs_pathway
   advance: antithrombotic + DAPT duration + cath strategy + statin + BB + (if ICI) steroids documented
10. 10DISPOSITION
    Telemetry / observation 24h if low-risk + troponin downtrending + stable; CICU if dynamic ECG / hemodynamic instability / refractory pain / cardiac MRI confirming ICI myocarditis; coordinate with oncology team for any planned chemotherapy interruption
    advance: disposition + level-of-care set + oncology partnership confirmed
11. 11MONITORING
    Continuous ECG + SpO2; repeat hsTn per 0/1-h pathway; CBC daily for CIT trajectory; bleeding signs per BARC 2011; QTc surveillance daily if methadone or QT-prolonging chemotherapy; KCCQ at 7 d if HF concern
    inputs: cbc_with_diff, creatinine_egfr
    actions: panel.cardiac, panel.renal
    advance: monitoring orders + cardio-onc partnership documented
12. 12FOLLOWUP
    Cardio-oncology clinic follow-up at 1 wk + 4 wk; oncology continuation decision re: chemotherapy hold/dose modification; cardiology long-term for any post-MI HF; mental health (cancer + cardiac dual-burden very high); palliative care if indicated; patient/family GOC re: future ICU + interventional escalation; primary care for medication reconciliation
    advance: cardio-onc + oncology + palliative care + mental health follow-up booked