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cardio.nstemi.high-risk.v1

High-risk NSTE-ACS (cath ≤24 h)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.nstemi.core.v1 — narrowed to the high-risk stratum (GRACE >140 / dynamic ECG / hemodynamic-electrical instability / refractory angina). Cath ≤24 h per ACC/AHA 2025 Class I + TIMACS PMID 19625657 (HR 0.65 in GRACE >140 subgroup) + VERDICT PMID 30156145 (HR 0.81 in high-risk). Inherits parent universal regimen (ASA + P2Y12 + parenteral AC + statin) and 5-pillar post-MI GDMT via routing through cardio.nstemi.core.v1. Specialises the trigger panel, ≤24 h cath orchestration, and shock / mechanical-complication branchpoints. Escalation criteria to very-high-risk (≤2 h cath): refractory angina on max med OR SCAI C+ shock OR sustained VT/VF — fires cardiogenic-shock engine + MCS per DanGer Shock 2024 PMID 38587234. Status INTEGRATED authored 2026-05-14 by shard-06-cardio-acute as part of the Phase E NSTEMI-by-stratum batch.

Entry points (5)

  • lab_abnormality
    GRACE >140 in NSTE-ACS context — early-invasive Class I per ACC/AHA 2025
    grace_above_140
  • imaging
    Dynamic ST depression ≥0.5 mm or transient ST elevation or deep T-wave inversion (high-risk feature, ACC/AHA 2025)
    dynamic_ecg_st_depression
  • symptom
    Refractory angina despite max medical therapy (Class I emergent → ≤2 h consideration)
    refractory_angina_on_max_med
  • symptom
    Hemodynamic instability (SBP <90, hypoperfusion) or sustained VT/VF in NSTE-ACS
    hemodynamic_or_electrical_instability
  • lab_abnormality
    High-sensitivity troponin rise/fall with dynamic ECG and ischemic context
    hstn_dynamic_rise_with_ischemia

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    GRACE/TIMI age component; influences cath timing in elderly per After Eighty / SENIOR-RITA frailty subanalyses
  • weightrequired
    demographic • used at CONTEXT
    Enoxaparin/UFH weight-based dosing; prasugrel weight ≥60 kg per TRITON-TIMI 38
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 = SCAI B-C shock screen → very-high-risk pathway (≤2 h cath); also GRACE component
  • hrrequired
    vital • used at CONTEXT
    Tachycardia component of GRACE; affects β-blocker initiation timing
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    Dynamic rise/fall over 1 h confirms NSTEMI within high-risk stratum (ESC 2023 0/1-h algorithm)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    GRACE creatinine component; contrast nephropathy planning before ≤24-h cath; KDIGO 2026
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline Hgb/platelets before triple antiplatelet+heparin upfront load
  • lipidsrequired
    lab • used at INITIAL_WORKUP
    High-intensity statin on day 0 per ACC/AHA 2025; baseline LDL for 4-8 wk recheck
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Serial ECG q15 min × first hour to detect dynamic changes / STEMI evolution
  • tte_bedsiderequired
    imaging • used at BRANCHING_WORKUP
    EF, RWMA, mechanical complication screen in high-risk before cath
  • bleeding_historyrequired
    history • used at CONTEXT
    Prasugrel CONTRAINDICATED if prior stroke/TIA; HAS-BLED gates triple-therapy duration

12-phase flow (12)

  1. 1FRAME
    Confirm high-risk NSTE-ACS stratum — GRACE >140 OR dynamic ECG OR hemodynamic/electrical instability OR refractory angina; route to parent cardio.nstemi.core.v1 for the universal regimen and add ≤24-h cath timing per ACC/AHA 2025 Class I + TIMACS PMID 19625657
    inputs: ecg_serial, hs_troponin_serial
    advance: High-risk stratum confirmed; very-high-risk (≤2 h) excluded
  2. 2ENTRY
    Triage with serial ECG + 0/1-h hsTn; calculate GRACE within first hour to confirm high-risk classification
    inputs: age
    advance: Pathway started + GRACE pending
  3. 3CONTEXT
    Allergies, baseline meds, OAC use (alters DAPT/triple plan), bleeding history (prasugrel contraindication screen), prior PCI/CABG
    inputs: sbp, hr, creatinine_egfr, bleeding_history
    advance: Context complete
  4. 4RED_FLAGS
    SBP <90 + hypoperfusion → SCAI C+ → escalate to very-high-risk (≤2 h cath + MCS standby); sustained VT/VF → ICU + cardiology now; new murmur/edema → mechanical complication branch
    inputs: sbp
    actions: acs_pathway, cardiogenic_shock, acute_valvular_emergency
    advance: Red flags screened + escalation triggered if needed
  5. 5INITIAL_WORKUP
    Serial ECG q15 min, 0/1-h hsTn, BMP, CBC, coags, lipids, A1c, CXR, type-and-screen pre-cath
    inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, cbc, lipids
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: High-risk workup complete
  6. 6BRANCHING_WORKUP
    Bedside echo for EF + mechanical complication; CT-A only if dissection suspicion (CT-A BEFORE heparin); avoid stress/CCTA — high-risk goes direct to cath
    inputs: tte_bedside
    actions: acute_valvular_emergency
    advance: Mechanical/dissection screen complete
  7. 7DIFFERENTIAL
    High-risk NSTE-ACS vs evolving STEMI vs type-2 MI vs Takotsubo vs myocarditis vs dissection per 4th UDMI 2018
    advance: NSTEMI type-1 confirmed
  8. 8RISK_STRATIFICATION
    Confirm GRACE >140 or other high-risk feature with HEART/TIMI cross-check; band-stratified disposition per Backus 2013 PMID 23414246 high-tier 65% MACE
    inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.grace
    advance: High-risk tier formally documented
  9. 9TREATMENT
    Universal ASA + ticagrelor (preferred upstream per PLATO + ISAR-REACT 5) + UFH or enoxaparin + atorvastatin 80; cath lab activated for ≤24 h window per ACC/AHA 2025 Class I + TIMACS (PMID 19625657 HR 0.65 in GRACE >140 subgroup)
    inputs: creatinine_egfr, cbc
    actions: protocol.stemi
    advance: High-risk antithrombotic load given + cath window booked
  10. 10DISPOSITION
    CICU or telemetry-to-cath-lab; transfer to PCI center if not on site (transfer time fits ≤24 h window per ACC/AHA 2025 systems-of-care)
    advance: Cath lab disposition + level-of-care set
  11. 11MONITORING
    Continuous ECG/SpO2, repeat hsTn to peak, BMP/CBC q6-12 h on AC, bleeding signs each shift per BARC 2011
    inputs: creatinine_egfr, cbc
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Cardiac rehab Class I, full 5-pillar GDMT, lipid recheck 4-8 wks per IMPROVE-IT, DAPT plan 12 mo standard or de-escalation per TWILIGHT/MASTER DAPT if HBR
    advance: Discharge bundle + cardiac rehab booked