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cardio.nstemi.core.v1

NSTEMI / NSTE-ACS (UA + NSTEMI)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

NSTE-ACS dossier (FULL §5.5 contract depth, reconciled 2026-05-14) — ED + inpatient + ICU + transition + outpatient setting playbooks (5 total); HEART/TIMI/GRACE-driven invasive timing per ACC/AHA 2025; universal ASA + P2Y12 + AC + statin; 5-pillar GDMT post-MI. regimen_axes[0] now encodes 5 phenotype steps — very-high-risk-≤2h / high-risk-≤24h / intermediate-≤72h / low-risk-ischemia-guided / type-2-MI-demand — each with appropriate antithrombotic + revasc timing per TIMACS (PMID 19458363) + VERDICT (PMID 30565996). Ticagrelor preferred per PLATO (PMID 19717846) + ISAR-REACT 5 (PMID 31475799); prasugrel only post-anatomy and not in prior stroke/TIA per TRITON-TIMI 38 (PMID 17982182); clopidogrel reserved for high-bleed-risk, on OAC, or low-risk medical management. DAPT de-escalation in HBR per TWILIGHT (PMID 31556978 — ticagrelor mono after 3 mo) and MASTER DAPT (PMID 34449185 — 1-mo DAPT then SAPT) per ACC/AHA 2025 Class IIa. Sibling differentiation vs STEMI and dissection — must rule out dissection before heparin per ACC/AHA 2025. HEART pathway band-stratified MACE per Backus 2013 (PMID 23465250): 0–3 → 0.99% / 4–6 → 11.6% / 7–10 → 65.2%; HEART AUC 0.83 superior to TIMI 0.78 / GRACE 0.70 per Poldervaart Int J Cardiol 2017 (PMID 27810290); US validation Mahler 2015 (PMID 25737484) supports 0% MACE in low-risk safe-discharge cohort. hsTn 0/1-h algorithm anchored on Reichlin NEJM 2009 (PMID 19710484) and Body JACC 2011 (PMID 21920261); dynamic ECG ST changes per Holmvang JACC 2003 (PMID 12651033); type-2 MI distinction per 4th UDMI (PMID 30153967). Open work for next session: live PubMed verification of identifier-pending PMIDs (ACC/AHA 2025 ACS Rao, ISIS-2, ACUITY, MATRIX, AVOID, BARC); RxNav validation of 21 RxCUIs via scripts/research/rxnav-validate.ts; manifest extension; engine-specific panel tests beyond the existing acs-panel.test.tsx.

Entry points (5)

  • symptom
    Ischemic-pattern chest pain or anginal equivalent (ACC/AHA 2025 ACS, Class I)
    ischemic_chest_pain
  • lab_abnormality
    High-sensitivity troponin elevation in appropriate clinical context (ESC 2023 0/1-h algorithm)
    hstn_elevation
  • imaging
    Dynamic ECG changes (ST depression ≥0.5 mm or T-wave inversion) per ACC/AHA 2021 Chest Pain §4.3
    dynamic_ecg_ischemia
  • symptom
    New rest angina within 48 h or accelerating angina (ACC/AHA 2025 ACS, high-risk feature)
    rest_angina_within_48h
  • history
    Known CAD presenting with change in pattern (ACC/AHA 2025 ACS)
    known_cad_with_change

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Risk stratification + drug selection (prasugrel ≤75 yr per TRITON-TIMI 38, Wiviott NEJM 2007); GRACE/TIMI age components
  • weightrequired
    demographic • used at CONTEXT
    Prasugrel weight ≥60 kg per TRITON-TIMI 38 (Wiviott NEJM 2007); enoxaparin renal dosing per ACC/AHA 2025
  • sbprequired
    vital • used at CONTEXT
    Hypotension = high-risk per GRACE score; affects β-blocker / nitrate use (ACC/AHA 2025 ACS)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia / bradycardia limit β-blocker; AF detection (ACC/AHA 2025 ACS, Class I)
  • spo2required
    vital • used at TREATMENT
    Oxygen only if SpO2 <90% (AVOID trial, Stub Circulation 2015); ACC/AHA 2025 Class III-harm for routine O2
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    0/1-h or 0/3-h ESC 2023 algorithm; rise/fall confirms NSTEMI (ESC 2023 §3.3)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Contrast nephropathy risk; enoxaparin / DOAC dose adjustment; PCI risk score (ACC/AHA 2025)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline Hgb / platelets before AC; transfusion threshold (ACC/AHA 2025 ACS, Class I)
  • coagrequired
    lab • used at INITIAL_WORKUP
    PT/PTT/INR baseline before parenteral AC (ACC/AHA 2025 ACS)
  • lipidsrequired
    lab • used at INITIAL_WORKUP
    Statin titration target LDL <70 / <55 in very-high-risk (ESC 2023 §5.5; ACC/AHA 2025)
  • a1c_glucoserequired
    lab • used at INITIAL_WORKUP
    Newly diagnosed DM common; SGLT2i candidacy (ADA 2026; ACC/AHA 2025)
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Dynamic changes = high-risk; rule out STEMI (ACC/AHA 2025, Class I; ESC 2023 §3.2)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Pulmonary edema, widened mediastinum (dissection rule-out), pneumothorax (ACC/AHA 2021 Chest Pain)
  • tte_bedside
    imaging • used at BRANCHING_WORKUP
    EF, RWMA, mechanical complications, pericardial effusion (ACC/AHA 2025, Class I for hemodynamic instability)
  • prior_cad_pci_cabgrequired
    history • used at CONTEXT
    Recurrent ACS shifts urgency; stent thrombosis differential (ACC/AHA 2025 ACS)
  • bleeding_historyrequired
    history • used at CONTEXT
    Prasugrel contraindicated if prior stroke / TIA (TRITON-TIMI 38, Wiviott NEJM 2007); risk-adjust DAPT duration per ACC/AHA 2025
  • current_medsrequired
    medication • used at CONTEXT
    Existing AC / antiplatelet / statin / BB; OAC for AF affects triple-therapy strategy (ACC/AHA 2025 ACS)

12-phase flow (12)

  1. 1FRAME
    Confirm NSTE-ACS (UA vs NSTEMI) vs STEMI vs type-2 MI vs dissection vs PE vs myo/pericarditis vs non-cardiac (ACC/AHA 2021 Chest Pain evaluation algorithm)
    inputs: ecg_serial, hs_troponin_serial
    advance: Diagnosis narrowed and STEMI excluded
  2. 2ENTRY
    Triage chest pain / equivalent with serial ECG and hsTn pathway per ESC 2023 0/1-h rapid rule-out algorithm
    inputs: age
    advance: Pathway started
  3. 3CONTEXT
    Risk factors, prior CAD, baseline meds, allergies, frailty, bleeding history per ACC/AHA 2025 ACS initial evaluation
    inputs: sbp, hr, creatinine_egfr, prior_cad_pci_cabg, bleeding_history, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability, refractory ischemia, ventricular arrhythmia, mechanical complication, suspected dissection — must rule out before heparin (ACC/AHA 2025, Class I)
    inputs: sbp, cxr
    actions: aortic_dissection, acs_pathway
    advance: Stabilised or escalated
  5. 5INITIAL_WORKUP
    Serial ECG q15min × first hour, 0/1-h or 0/3-h hsTn pathway (ESC 2023), BMP, CBC, coags, lipids, A1c, CXR per ACC/AHA 2025 §4
    inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, cbc, coag, lipids, a1c_glucose, cxr
    actions: panel.cardiac, panel.cbc, panel.lipid, panel.glucose_a1c, panel.renal
    advance: First-tier workup complete
  6. 6BRANCHING_WORKUP
    Bedside echo, CT-A if dissection suspicion, stress / CCTA in low-risk troponin-negative per ACC/AHA 2021 Chest Pain pathway
    inputs: tte_bedside
    actions: workup.aortic_dissection, workup.chest_pain
    advance: Branch resolved
  7. 7DIFFERENTIAL
    STEMI / NSTEMI / UA / type-2 MI / Takotsubo / myocarditis / dissection / PE / pericarditis / GERD / MSK — Fourth Universal Definition of MI 2018
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    HEART / TIMI-NSTEMI / GRACE 2.0; high-risk = early invasive ≤24 h (TIMACS, Mehta NEJM 2009; ACC/AHA 2025 Class I)
    inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.grace
    advance: Risk tier documented
  9. 9TREATMENT
    Universal ASA + P2Y12 + parenteral AC + high-intensity statin (ACC/AHA 2025 Class I); β-blocker oral if no shock; ACEi/ARB if EF<40 / HTN / DM / CKD; nitrate / opioid as needed; oxygen only if SpO2 <90% (AVOID trial 2015); SGLT2i if DM2 + ASCVD or HFrEF
    inputs: creatinine_egfr, lipids, cbc
    advance: Acute regimen + invasive plan documented
  10. 10DISPOSITION
    Cath lab and ICU vs telemetry ward; transfer if PCI not on site (ACC/AHA 2025 ACS systems-of-care recommendation)
    advance: Disposition + level of care set
  11. 11MONITORING
    Telemetry, serial troponin, renal function on AC, bleeding signs, ECG with each pain (ACC/AHA 2025 ACS, Class I)
    inputs: creatinine_egfr, cbc
    actions: panel.cardiac, panel.renal, panel.cbc
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Cardiac rehab (ACC/AHA 2025 Class I), GDMT optimisation, lipid recheck 4–8 wks, DAPT duration plan per PLATO / TWILIGHT, lifestyle, vaccinations
    advance: Follow-up booked + plan written