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cardio.nstemi.dialysis-troponin-interpretation.v1

NSTEMI in dialysis/ESKD — troponin delta (not absolute) drives diagnosis; renally-reconciled therapy

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Phase E variant of cardio.nstemi.core.v1 — narrowed to maintenance-dialysis/advanced-CKD NSTEMI centred on the troponin-interpretation problem. Cardiac troponin (especially hs-cTnT) is chronically elevated at baseline in ESKD from reduced clearance + subclinical injury + LVH + uraemic cardiomyopathy; cardiovascular death is the leading mortality cause. KEY DIFFERENCES FROM PARENT: diagnosis rests on a DYNAMIC rise/fall plus ischaemic context (4th UDMI) — a significant DELTA (commonly ≥20% from an elevated baseline or beyond assay biological variation), NOT a single absolute value; a documented prior baseline troponin and the specific assay (hs-cTnT > hs-cTnI elevation in ESKD) are essential. Antithrombotics are renally reconciled: UFH preferred (titratable, not renally cleared), fondaparinux contraindicated in severe renal failure, enoxaparin renally reduced + anti-Xa monitored. ESKD is a risk AMPLIFIER and must NOT trigger down-triage from a timely invasive strategy (dialysis patients are systematically under-revascularised yet benefit); ISCHEMIA-CKD informs STABLE disease, not ACS. The differential of a troponin rise is broad (type 2 from intradialytic hypotension/anaemia/high-output fistula, myocarditis, PE, uraemic pericarditis) and must be adjudicated before reflexive anticoagulation/catheterisation. Establish a new post-event baseline for future interpretation. Manifest pointer reuses cardio.nstemi.core.v1 manifest. Design-brief pointer reuses parent (ESKD-specific differences documented inline). Document the assay and individualised delta threshold in the record. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as ESKD/dialysis NSTEMI troponin-interpretation variant. Sister-differentiated from core, type2, and octogenarian-conservative.

Entry points (6)

  • symptom
    Chest pain or anginal equivalent (dyspnoea, fatigue, intradialytic hypotension) in a maintenance-dialysis / advanced-CKD patient — NSTEMI with troponin-interpretation challenge
    chest_pain_or_anginal_equivalent_in_dialysis_patient
  • lab_abnormality
    Troponin above the 99th-percentile URL in an ESKD patient — must establish whether this is a chronic stable baseline or an acute rise/fall
    troponin_elevated_above_url_in_eskd
  • lab_abnormality
    Significant serial troponin change (rise and/or fall, e.g. ≥20% from an elevated baseline or beyond assay biological variation) in a dialysis patient with ischaemic context — acute MI signature
    significant_serial_troponin_delta_in_dialysis
  • vital_abnormality
    Recurrent intradialytic hypotension with chest pain / ST-T changes — peri-dialytic demand ischaemia vs type 1 NSTEMI
    intradialytic_hypotension_with_ischaemic_features
  • history
    Prior known baseline troponin value available in an ESKD patient now symptomatic — enables delta-based interpretation (high diagnostic value)
    known_baseline_troponin_value_available
  • imaging
    New ischaemic ECG changes (dynamic ST depression / T-wave inversion) in a dialysis patient — confounded by LVH/repolarisation; integrate with troponin delta + symptoms
    ischaemic_ecg_changes_in_dialysis_patient

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    ESKD patients have markedly elevated cardiovascular mortality across ages; informs invasive-strategy and bleeding-risk balance
  • sex
    demographic • used at CONTEXT
    Sex modifies troponin URLs and presentation; relevant to assay-specific interpretation
  • dialysis_modality_schedule_and_anuria_statusrequired
    history • used at FRAME
    Haemodialysis vs peritoneal, last/next session timing, residual renal function and anuria status drive peri-dialytic risk, anticoagulant choice and contrast considerations
  • troponin_assay_used_and_prior_baseline_valuerequired
    history • used at INITIAL_WORKUP
    hs-cTnT is more elevated at baseline in ESKD than hs-cTnI; a documented prior baseline transforms an absolute value into an interpretable delta
  • chest_painrequired
    symptom • used at ENTRY
    Anchor symptom; atypical equivalents (dyspnoea, intradialytic hypotension, fatigue) are common from autonomic neuropathy
  • serial_troponinrequired
    lab • used at INITIAL_WORKUP
    Serial measurement (0/1-2-3 h per assay) to establish a rise/fall pattern — the diagnostic cornerstone in chronically elevated baselines
  • twelve_lead_ecgrequired
    imaging • used at ENTRY
    Ischaemia assessment, confounded by LVH/strain and electrolyte shifts; serial ECGs around dialysis add value
  • electrolytesrequired
    lab • used at INITIAL_WORKUP
    Potassium/calcium shifts peri-dialysis affect ECG and arrhythmic/ischaemic risk and antiarrhythmic safety
  • hemoglobinrequired
    lab • used at BRANCHING_WORKUP
    Anaemia of CKD is a major demand-ischaemia (type 2 MI) driver and a bleeding/transfusion consideration for an invasive strategy
  • bleed_risk_and_vascular_access_for_dialysisrequired
    history • used at RISK_STRATIFICATION
    AV fistula/graft preservation and elevated bleeding risk in uraemia shape antithrombotic dosing and radial-vs-femoral access planning

12-phase flow (11)

  1. 1FRAME
    NSTEMI in ESKD: troponin is chronically elevated at baseline (especially hs-cTnT); diagnosis depends on a DYNAMIC rise/fall plus ischaemic context (4th UDMI), not a single absolute value. Cardiovascular death is the leading mortality cause; dialysis patients are systematically under-revascularised
    inputs: dialysis_modality_schedule_and_anuria_status
    advance: delta-based diagnostic frame + ESKD context established
  2. 2ENTRY
    Characterise presentation (typical vs atypical equivalent, relation to the dialysis session); 12-lead ECG (interpret against LVH/strain baseline); start serial troponin with the specific assay; identify whether a prior baseline troponin exists
    inputs: chest_pain, twelve_lead_ecg
    advance: presentation characterised + serial troponin initiated
  3. 3CONTEXT
    Dialysis modality/schedule/anuria, residual renal function, vascular access type, anaemia, prior CAD/revascularisation, intradialytic-hypotension pattern, transplant candidacy, bleeding history
    inputs: age
    advance: context complete
  4. 4RED_FLAGS
    Ongoing ischaemic pain, haemodynamic instability, dynamic ST changes, malignant arrhythmia, severe hyperkalaemia-driven ECG changes mimicking/masking ischaemia, pulmonary oedema from volume overload, mechanical complication — any mandate urgent therapy and consideration of immediate invasive strategy
    actions: acs_pathway
    advance: high-risk/very-high-risk features screened
  5. 5INITIAL_WORKUP
    Serial hs-troponin with the institution's assay (interpret as a DELTA against any known baseline; absent a baseline, use the rise/fall pattern + assay biological variation), serial ECG (peri-dialytic), electrolytes, CXR for volume, bedside echo for wall-motion/effusion. Document the assay used
    inputs: serial_troponin, troponin_assay_used_and_prior_baseline_value, electrolytes
    actions: panel.cardiac, panel.renal
    advance: rise/fall pattern interpreted against baseline + assay documented
  6. 6BRANCHING_WORKUP
    Adjudicate type 1 (plaque rupture) vs type 2 MI (intradialytic hypotension, anaemia, high-output AV-fistula demand) vs non-ischaemic troponin elevation (myocarditis, PE, uraemic pericarditis, decompensated uraemic cardiomyopathy). Echo, consider CTPA if PE features; correlate troponin trajectory with the dialysis timeline
    inputs: hemoglobin
    actions: panel.coag
    advance: MI type / non-ischaemic cause adjudicated
  7. 7RISK_STRATIFICATION
    GRACE/HEART interpreted with ESKD as a strong risk amplifier; do NOT down-triage on ESKD alone. Decide invasive vs ischaemia-guided strategy (ISCHEMIA-CKD informs stable disease; ACS NSTEMI still benefits from a timely invasive strategy in suitable patients). Plan bleeding mitigation (radial access, renally-dosed antithrombotics, dialysis timing)
    inputs: bleed_risk_and_vascular_access_for_dialysis
    actions: calc.heart
    advance: MI type + invasive-strategy decision + bleeding-mitigation plan documented
  8. 8TREATMENT
    Confirmed type 1 NSTEMI: aspirin + P2Y12 inhibitor (ticagrelor not renally dose-adjusted; clopidogrel acceptable; prasugrel per criteria), anticoagulation with UFH (preferred in dialysis — titratable, not renally cleared) rather than weight-uncorrected enoxaparin; high-intensity statin; cautious beta-blocker; nitrates for ischaemia/oedema; AVOID fondaparinux in severe renal failure and reconcile enoxaparin/DOAC doses to renal function. Coordinate timely coronary angiography ± revascularisation with radial access and peri-procedural dialysis/electrolyte planning. Type 2 MI: treat the demand driver (optimise intradialytic haemodynamics, correct anaemia, address high-output fistula) rather than reflexively anticoagulating/catheterising
    inputs: bleed_risk_and_vascular_access_for_dialysis
    advance: MI-type-appropriate therapy initiated with renal reconciliation + access plan
  9. 9DISPOSITION
    Admit to a monitored cardiac bed; coordinate with nephrology for dialysis scheduling around any planned angiography; ICU/CCU if instability, arrhythmia or refractory ischaemia
    advance: monitored disposition + nephrology coordination documented
  10. 10MONITORING
    Serial troponin trajectory (confirm the rise/fall), telemetry (arrhythmia risk amplified by electrolyte shifts), peri-dialytic ischaemia surveillance, bleeding surveillance on antithrombotics, renal/electrolyte management with nephrology, post-PCI access + fistula checks
    actions: panel.cardiac
    advance: trajectory + post-treatment monitoring stable
  11. 11FOLLOWUP
    Establish/record a new post-event baseline troponin for future interpretation; secondary prevention (statin, antiplatelet duration balanced against high bleeding risk, BP/volume control via dialysis prescription, anaemia management); cardiology–nephrology shared care; transplant-evaluation cardiac clearance if a candidate; document the assay used and the individualised delta threshold
    advance: new baseline troponin + secondary prevention + shared-care plan documented