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cardio.nstemi.intermediate-risk.v1

Intermediate-risk NSTE-ACS (cath 25-72 h)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.nstemi.core.v1 — narrowed to the intermediate-risk stratum (GRACE 109-140 / rising hsTn without dynamic ECG / DM-CKD without high-risk features). Cath 25-72 h per ACC/AHA 2025 Class IIa + ESC 2023 PMID 37622670 — TIMACS PMID 19625657 showed no benefit of immediate cath in this stratum. Inherits parent universal regimen (ASA + P2Y12 + AC + statin) and 5-pillar post-MI GDMT via routing through cardio.nstemi.core.v1. Specialises trigger panel, 25-72 h cath orchestration, LMWH-preferred AC choice (vs UFH-preferred in high-risk). Re-classification triggers: new dynamic ECG → high-risk engine; new SBP <90 + hypoperfusion → cardiogenic-shock engine. HAS-BLED ≥3 favors short-DAPT per TWILIGHT/MASTER DAPT — this stratum has tighter ischemic-vs-bleed balance than high-risk. 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 109-140 in NSTE-ACS context — intermediate stratum, cath 25-72 h per ACC/AHA 2025 IIa
    grace_109_to_140
  • lab_abnormality
    Rising hsTn without dynamic ECG changes — intermediate-risk feature
    rising_troponin_no_dynamic_ecg
  • history
    Diabetes or CKD presenting with NSTE-ACS lacking high-risk features
    diabetes_or_ckd_without_high_risk_features
  • history
    Recent PCI/CABG presenting with NSTE-ACS pattern but no recurrent angina
    recent_pci_cabg_without_recurrent_angina
  • symptom
    hsTn-positive chest pain without dynamic ECG OR refractory angina
    biomarker_positive_chest_pain_without_dynamic_ecg

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    GRACE/TIMI age component; gates frailty + cath timing tradeoffs
  • weightrequired
    demographic • used at CONTEXT
    Enoxaparin / UFH weight-based dosing
  • sbprequired
    vital • used at CONTEXT
    Hypotension would re-classify to high-risk; baseline for BB titration
  • hrrequired
    vital • used at CONTEXT
    GRACE component; titration of BB after invasive plan
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    0/1-h or 0/3-h ESC 2023 algorithm — confirms NSTEMI but rule out dynamic rise that would re-classify
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Contrast nephropathy planning before 25-72 h cath; KDIGO 2026
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline Hgb/platelets before AC
  • lipidsrequired
    lab • used at INITIAL_WORKUP
    High-intensity statin per ACC/AHA 2025
  • a1c_glucoserequired
    lab • used at INITIAL_WORKUP
    Newly diagnosed DM common in intermediate stratum; SGLT2i candidacy
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Re-screen for dynamic changes that would re-classify to high-risk
  • tte_bedside
    imaging • used at BRANCHING_WORKUP
    EF + RWMA — EF<40 + intermediate features still warrants 25-72 h cath

12-phase flow (12)

  1. 1FRAME
    Confirm intermediate-risk NSTE-ACS — GRACE 109-140 OR rising hsTn without dynamic ECG OR DM/CKD without high-risk features. Route through parent cardio.nstemi.core.v1 for universal regimen, schedule cath 25-72 h per ACC/AHA 2025 Class IIa + ESC 2023
    inputs: ecg_serial, hs_troponin_serial
    advance: Intermediate stratum confirmed; high-risk features formally excluded
  2. 2ENTRY
    Triage with serial ECG + 0/1-h hsTn; calculate GRACE within first hour; plan delayed-invasive disposition
    inputs: age
    advance: Pathway started + GRACE pending
  3. 3CONTEXT
    Allergies, baseline meds, OAC use, bleeding history, prior PCI/CABG, comorbidities (DM, CKD)
    inputs: sbp, hr, creatinine_egfr
    advance: Context complete
  4. 4RED_FLAGS
    Re-check for high-risk re-classification triggers (new dynamic ECG, refractory angina, hemodynamic/electrical instability) — would escalate to high-risk engine
    inputs: sbp
    actions: acs_pathway
    advance: No high-risk re-classification triggers present
  5. 5INITIAL_WORKUP
    Serial ECG, 0/1-h hsTn, BMP, CBC, coags, lipids, A1c, CXR per ACC/AHA 2025 §4
    inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, cbc, lipids, a1c_glucose
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Intermediate workup complete
  6. 6BRANCHING_WORKUP
    Bedside echo in selected (instability, EF<40 suspicion, mechanical complication screen). Stress test or CCTA NOT used here — intermediate goes to cath, not deferred testing
    inputs: tte_bedside
    actions: chest_pain
    advance: Echo + branchpoints resolved
  7. 7DIFFERENTIAL
    Intermediate-risk NSTE-ACS vs type-2 MI vs Takotsubo vs myocarditis per 4th UDMI 2018
    advance: Type-1 MI confirmed
  8. 8RISK_STRATIFICATION
    GRACE 109-140 confirmed; HEART 4-6 (band-stratified 11.6% 30-d MACE per Backus PMID 23414246); TIMI 2-4 typical
    inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.grace
    advance: Intermediate tier formally documented
  9. 9TREATMENT
    Universal ASA + P2Y12 (ticagrelor preferred per PLATO + ISAR-REACT 5) + enoxaparin (LMWH preferred for non-imminent cath per ESSENCE PMID 11519503) + atorvastatin 80; cath 25-72 h per ACC/AHA 2025 Class IIa — no immediate-cath benefit in this stratum per TIMACS PMID 19625657
    inputs: creatinine_egfr, cbc
    advance: Standard load given + cath window booked
  10. 10DISPOSITION
    Telemetry ward typical; CICU only if comorbidity-driven (advanced HF, severe CKD on dialysis); transfer to PCI center if not on site (window allows interfacility transfer)
    advance: Disposition + level-of-care set
  11. 11MONITORING
    Continuous ECG/SpO2, repeat hsTn to peak, BMP/CBC q12 h on AC, bleeding signs each shift; re-trigger high-risk pathway if dynamic ECG develops
    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, DAPT 12 mo standard or de-escalation per TWILIGHT/MASTER DAPT if HBR
    advance: Discharge bundle + cardiac rehab booked