Patient handout

High-risk NSTE-ACS (cath ≤24 h)

PRODUCTION

1. Your condition

This handout is for high-risk nste-acs (cath ≤24 h). Your care team identified this based on: grace >140 in nste-acs context — early-invasive class i per acc/aha 2025.

Other reasons your team may use this plan: dynamic st depression ≥0.5 mm or transient st elevation or deep t-wave inversion (high-risk feature, acc/aha 2025); refractory angina despite max medical therapy (class i emergent → ≤2 h consideration); hemodynamic instability (sbp <90, hypoperfusion) or sustained vt/vf in nste-acs.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
aspirin	162-325 mg load → 81 mg	PO chewed	load once → 81 mg daily lifelong	Universal — ACC/AHA 2025 Class I; ISIS-2 23% mortality reduction
ticagrelor	180 mg load → 90 mg BID	PO	BID × 12 mo standard DAPT	PLATO PMID 19717846 + ISAR-REACT 5 PMID 31475799 — preferred upstream of anatomy in high-risk; ACC/AHA 2025 Class I
clopidogrel	600 mg load → 75 mg	PO	daily × 12 mo	Alternative for HBR or on chronic OAC (AUGUSTUS / ENTRUST-AF PCI); ACC/AHA 2025 Class IIa
unfractionated_heparin	60 U/kg bolus (max 4000) → 12 U/kg/h infusion	IV	continuous, aPTT 1.5-2× control	ACC/AHA 2025 Class I default for invasive ≤24 h; reversible; renal-friendly
enoxaparin	1 mg/kg SC q12h (1 mg/kg q24h if CrCl 15-30)	SC	q12h until 24 h pre-cath then switch to UFH	ESSENCE PMID 11519503; switch to UFH at PCI per ACC/AHA 2025
atorvastatin	80 mg	PO	once daily	PROVE-IT PMID 15007110 — start day 0 high-intensity per ACC/AHA 2025 Class I

Plan: High-risk NSTE-ACS upfront triple antithrombotic load (ASA + P2Y12 + UFH/enoxaparin) — ACC/AHA 2025 Class I; ≤24 h cath

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent chest pain → ED
BARC 2+ bleed → reassess DAPT — TWILIGHT PMID 31475798 or MASTER DAPT PMID 34516952 if HAS-BLED ≥3
NYHA worsening to III+ → expedite cardiology re-eval + echo

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

GRACE >140 in NSTE-ACS context — high-risk stratum requiring cath ≤24 h per ACC/AHA 2025 Class I
New dynamic ST depression ≥0.5 mm or transient ST elevation or deep T-wave inversion during NSTE-ACS workup
Refractory angina despite max medical therapy — escalates to very-high-risk (≤2 h cath) per ACC/AHA 2025 Class I(life-threatening)
SBP <90 with hypoperfusion OR sustained VT/VF in high-risk NSTE-ACS — escalate to ≤2 h cath + MCS standby(life-threatening)
New harsh murmur, pulmonary edema, or papillary rupture / VSD / free-wall rupture during high-risk NSTE-ACS(life-threatening)

5. Follow-up

Cardiac rehab Class I, full 5-pillar the four foundational heart-failure medications, lipid recheck 4-8 wks per IMPROVE-IT, DAPT plan 12 mo standard or de-escalation per TWILIGHT/MASTER DAPT if HBR

6. Sources

Guideline: 2025 ACC/AHA Guideline for ACS (Rao); ESC 2023 NSTE-ACS Guideline (Byrne, PMID 37622670)