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cardio.nstemi.octogenarian-conservative.v1

Octogenarian NSTE-ACS — conservative strategy

cardiologyacuteadultgeriatricacuteinpatienttransitionoutpatient
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Phase E variant of cardio.nstemi.core.v1 — narrowed to age ≥80 with conservative-strategy decision after frailty + bleed-risk shared decision per ACC/AHA 2025 ACS elderly section + SENIOR-NSTEMI registry (PMID 32605898) + After Eighty (PMID 26794722). Inherits parent universal regimen via routing; specialises antiplatelet selection (clopidogrel preferred; AVOID prasugrel age >75 / wt <60 per FDA boxed warning), parenteral AC (fondaparinux preferred per OASIS-5 PMID 16554528 if eGFR ≥20), DAPT duration (3-6 mo if HBR per MASTER DAPT PMID 34516952 + PRECISE-DAPT PMID 28290994), AKI prophylaxis (KDIGO 2026 pre-hydration), and statin intensity (frailty-adjusted). Override path: hemodynamic / electrical instability OR refractory angina escalates to high-risk engine + cardiogenic-shock screen with reaffirmation of shared decision; functional baseline still gates MCS in octogenarians. Co-management with geriatrics if CFS ≥6 or polypharmacy >10 meds; pharmacy-led Beers review pre-discharge; falls + delirium screening per shift. Status INTEGRATED authored 2026-05-15 by shard-06-cardio-acute as part of the Phase E NSTEMI-by-cohort batch.

Entry points (4)

  • demographic
    Age ≥80 + NSTE-ACS confirmed by 0/1-h hsTn algorithm — shared-decision invasive vs conservative per ACC/AHA 2025
    age_ge_80_with_nsteacs
  • history
    Clinical Frailty Scale (Rockwood) ≥5 — mild-moderate frailty drives risk-benefit toward conservative
    cfs_rockwood_ge_5_with_nsteacs
  • history
    Meets ARC-HBR major or 2 minor criteria → high bleed risk drives conservative + short DAPT (MASTER DAPT)
    arc_hbr_high_bleed_with_nsteacs
  • lab_abnormality
    eGFR <30 + age ≥80 + NSTE-ACS — contrast nephropathy risk weighs against early cath
    egfr_below_30_with_nsteacs

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Age ≥80 defines this cohort; prasugrel CONTRAINDICATED >75 per FDA; ticagrelor still acceptable but bleed risk higher per PLATO subgroup
  • weightrequired
    demographic • used at CONTEXT
    Prasugrel CONTRAINDICATED <60 kg; enoxaparin weight-based; falls + low weight = HBR per ARC-HBR
  • frailty_scorerequired
    history • used at RISK_STRATIFICATION
    Clinical Frailty Scale (Rockwood) or Fried phenotype drives invasive-vs-conservative shared decision per ACC/AHA 2025 + SENIOR-RITA
  • falls_historyrequired
    history • used at CONTEXT
    ≥1 fall in last 6 mo = ARC-HBR minor; gates DAPT duration + intensity
  • bleeding_historyrequired
    history • used at CONTEXT
    Prior major bleed = ARC-HBR major; absolute contraindication to prasugrel (also age >75 / wt <60 per FDA)
  • medication_list_polypharmacyrequired
    history • used at CONTEXT
    Polypharmacy ADE screen (Beers); concomitant OAC alters DAPT plan (AUGUSTUS); SSRI + NSAID + steroids amplify bleed
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension overrides conservative path → re-categorise to very-high-risk and reassess shared decision
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    ESC 2023 0/1-h hsTn confirms NSTEMI within elderly cohort; chronic elevation common in CKD/HF — dynamic delta required
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    eGFR drives contrast nephropathy risk + enoxaparin/DOAC dosing; KDIGO 2026 pre-hydration if proceeding
  • hgb_baselinerequired
    lab • used at INITIAL_WORKUP
    Hgb <11 g/dL female / <12 male = ARC-HBR major; gates DAPT duration
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    <100k = ARC-HBR major; affects antiplatelet plan
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Serial ECG for dynamic changes — escalates to invasive even in elderly per ACC/AHA 2025 high-risk feature
  • tte_bedsiderequired
    imaging • used at BRANCHING_WORKUP
    Baseline EF + RWMA + valvular screen; conservative path still wants echo for risk stratification

12-phase flow (12)

  1. 1FRAME
    Confirm NSTE-ACS in age ≥80; flag elderly-specific shared decision (invasive vs conservative) per ACC/AHA 2025; route to parent cardio.nstemi.core.v1 for the universal regimen with elderly-specific antiplatelet + AKI + DAPT-duration overrides
    inputs: ecg_serial, hs_troponin_serial
    advance: NSTE-ACS confirmed in ≥80 patient
  2. 2ENTRY
    Triage with serial ECG + 0/1-h hsTn; prompt frailty assessment within first hour; flag ARC-HBR criteria upfront
    inputs: age, weight
    advance: Pathway started + frailty + ARC-HBR scored
  3. 3CONTEXT
    Polypharmacy reconciliation (Beers), falls history, bleeding history, OAC, baseline cognition + functional status, advance directives
    inputs: frailty_score, falls_history, bleeding_history, medication_list_polypharmacy, sbp, creatinine_egfr
    advance: Geriatric context complete
  4. 4RED_FLAGS
    Hemodynamic instability / sustained VT/VF / refractory angina overrides conservative path → escalate to high-risk engine + cardiogenic shock screen; new murmur / pulmonary edema → mechanical complication branch
    inputs: sbp
    actions: acs_pathway, cardiogenic_shock
    advance: Red flags screened
  5. 5INITIAL_WORKUP
    Serial ECG, 0/1-h hsTn, BMP (eGFR), CBC (Hgb + plt), coags, lipids, A1c, CXR; gentle hydration plan if cath becomes necessary per KDIGO 2026
    inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, hgb_baseline, platelets
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Workup complete
  6. 6BRANCHING_WORKUP
    Bedside echo for EF + RWMA + valvular; consider non-invasive ischemia testing only if conservative path elected and patient stable; defer stress imaging if frailty CFS ≥6 (low yield + high adverse-event rate)
    inputs: tte_bedside
    actions: chest_pain
    advance: Non-invasive workup complete
  7. 7DIFFERENTIAL
    Type-1 vs type-2 MI per 4th UDMI; CKD + HFpEF + sepsis-related troponin elevation common in elderly; differential affects strategy
    advance: NSTEMI type confirmed
  8. 8RISK_STRATIFICATION
    Compute HEART, TIMI-NSTEMI, GRACE; cross-with frailty (CFS) + ARC-HBR + PRECISE-DAPT to land on invasive vs conservative shared-decision recommendation; document ischemic vs bleed risk explicitly
    inputs: age, weight, sbp, creatinine_egfr, hs_troponin_serial, frailty_score
    actions: calc.heart, calc.timi_nstemi, calc.has_bled, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: Shared decision documented with patient/family
  9. 9TREATMENT
    Conservative path: ASA + clopidogrel (preferred over ticagrelor in CFS ≥5 / Hgb-platelet HBR; AVOID prasugrel age >75 or wt <60 per FDA); fondaparinux preferred AC if eGFR ≥20 (OASIS-5 lower bleed); high-intensity statin or moderate if frailty CFS ≥6 + life-expectancy <2 y; conservative GDMT initiation with go-slow titration
    inputs: creatinine_egfr, hgb_baseline
    actions: protocol.stemi
    advance: Conservative regimen + DAPT plan finalised
  10. 10DISPOSITION
    Telemetry on cardiology service; goals-of-care + advance-directive review; involve geriatrics if CFS ≥6 or polypharmacy >10 meds; family meeting if shared decision elected conservative path
    advance: Disposition + goals-of-care documented
  11. 11MONITORING
    Continuous ECG + SpO2; daily Hgb + BMP first 48 h; bleeding signs each shift per BARC 2011; falls precautions; delirium screen (CAM) q shift; mobility + nutrition supportive
    inputs: creatinine_egfr, hgb_baseline
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Cardiac rehab (geriatric-tailored) Class I; lipid recheck 4-8 wks; PRECISE-DAPT-driven DAPT duration (3-6 mo if HBR per MASTER DAPT) with explicit reassessment cadence; geriatrics co-management if frail
    advance: Discharge bundle + cardiac rehab booked + DAPT-duration plan documented