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cardio.nstemi.post-cabg-perioperative.v1

NSTEMI peri-operative — within 30 days post-CABG (UDMI Type 5 NSTEMI variant)

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Phase E peri-operative variant of cardio.nstemi.core.v1 — narrowed to NSTEMI within 30 days post-CABG per 4th UDMI Type 5 criteria (Thygesen Circulation 2018 PMID 30153967): cTn >10× URL cTnT (or >35× URL cTnI) within 48 h of CABG (or sustained rise/re-rise after expected post-pump fall), PLUS new Q waves / new LBBB / new occlusion / new RWMA, AND no STE. Three drivers to discriminate per Wang Circulation 2022 PMID 35105183: (1) early graft thrombosis (focal RWMA + culprit on cath; PCI of graft with embolic protection per SAFER PMID 11815441 vs native distal PCI when feasible); (2) distal embolization / incomplete revasc (diffuse, often non-territorial; optimal medical therapy); (3) type-2 peri-op demand ischemia (anemia, hypotension, AF/RVR, sepsis; trigger-targeted therapy first). Anti-thrombotic complexity: most patients on chronic ASA + clopidogrel post-CABG per POPULAR-CABG PMID 34016267; chest tube output + sternal dehiscence + active surgical bleed gates UFH + DAPT escalation — cardiac surgery clearance mandatory before P2Y12 reload or ticagrelor escalation in first 7 d. UFH preferred over LMWH/fondaparinux for reversibility (protamine). Transfusion threshold: TRICS-III PMID 29214843 set restrictive 7.5 in cardiac surgery but ACTIVE MI raises threshold to Hgb >9 to correct type-2 demand component. Sister engines: cardio.stemi.post-cabg-mi.v1 (STEMI variant — STE present; any time post-CABG); cardio.nstemi.type2.v1 (broader supply-demand mismatch; no temporal context); cardio.cardiogenic-shock.post-cabg.v1 (hemodynamic instability stratum). Override paths: STE evolution → STEMI variant; SCAI B+ → cardiogenic-shock variant. Status INTEGRATED authored 2026-05-15 by shard-06-cardio-acute as part of the Phase E NSTEMI-by-context wave 24.

Entry points (5)

  • history
    Troponin rise meeting UDMI Type 5 NSTEMI threshold (>10× URL cTnT / >35× URL cTnI within 48 h of CABG, OR sustained rise after expected post-pump fall) without ST elevation
    nstemi_within_30d_post_cabg
  • lab_abnormality
    Post-CABG troponin re-rise (after the expected initial post-pump fall toward baseline by 24-72 h) — graft thrombosis or distal embolization suspect
    troponin_re_rise_post_initial_post_pump_fall
  • symptom
    Recurrent ischemic chest pain (or angina-equivalent: dyspnea, diaphoresis, hypotension) within 30 days post-CABG without STE
    recurrent_ischemic_chest_pain_post_cabg_window
  • imaging
    New regional wall-motion abnormality on post-CABG echo (vs pre-op or immediate post-op baseline) without STE — territorial graft failure suspect
    new_rwma_on_post_cabg_echo
  • vital_abnormality
    Unexplained hypotension, AF with RVR, or hemodynamic instability in post-CABG patient with rising troponin and no STE — type-2 demand vs early graft thrombosis triage
    unexplained_hypotension_or_arrhythmia_post_cabg_with_trop

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Post-CABG patients skew older; bleed + AKI risk modify cath + DAPT decisions
  • cabg_operative_detailsrequired
    history • used at FRAME
    CABG date (days post-op critical), grafts placed (LIMA-LAD, SVG-OM, SVG-RCA, etc.), residual ungrafted disease per surgical report, intra-op events (long pump time, difficult anastomosis, on/off-pump) — drives culprit-vessel hypothesis + peri-op MI classification
  • troponin_baseline_and_serialrequired
    lab • used at INITIAL_WORKUP
    UDMI Type 5 requires >10× URL cTnT (or >35× URL cTnI) AND additional criterion (Q wave, occlusion, RWMA); baseline post-pump trop expected elevated — pattern (sustained rise vs fall toward baseline) is diagnostic
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Confirm absence of STE (this is NSTEMI variant); detect new Q waves, new LBBB, ST depression / T inversion patterns; routine post-CABG ECG changes (pericarditis pattern, BBB) confound
  • echo_with_baseline_comparisonrequired
    imaging • used at INITIAL_WORKUP
    Compare to pre-op + immediate post-op echo for new RWMA — UDMI Type 5 imaging criterion; also pericardial effusion (post-CABG) + tamponade (sternotomy adhesion masks classic signs)
  • hgb_baselinerequired
    lab • used at CONTEXT
    Peri-op anemia drives type-2 demand; TRICS-III restrictive Hgb 7.5 threshold in cardiac surgery (PMID 29214843) — but if MI suspected lower threshold for transfusion to >8-9
  • creatinine_egfrrequired
    lab • used at CONTEXT
    Post-CPB AKI common; gates contrast volume + DOAC dosing + cath risk-benefit per KDIGO 2026
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension as both trigger (type-2 demand) and red flag (graft thrombosis with shock); MAP <65 → vasopressor + cath consideration
  • hrrequired
    vital • used at CONTEXT
    AF with RVR is most common post-CABG arrhythmia (30-40% incidence) and a frequent type-2 trigger; rate control is primary therapy
  • current_post_cabg_medsrequired
    medication • used at CONTEXT
    Most patients on chronic ASA + clopidogrel post-CABG (POPULAR-CABG PMID 34016267); chest-tube output + sternotomy bleed risk gates UFH + P2Y12 escalation; coordinate with CT-surgery before loading
  • chest_tube_output_and_sternal_statusrequired
    history • used at RED_FLAGS
    Active chest tube bleeding + sternal dehiscence risk → contraindication to UFH escalation; CT-surgery clearance required before DAPT load in first 7 d

12-phase flow (12)

  1. 1FRAME
    Confirm post-CABG NSTEMI per 4th UDMI Type 5 (Thygesen 2018 PMID 30153967): cTn >10× URL cTnT (or >35× URL cTnI) within 48 h of CABG, OR sustained rise/re-rise after expected post-pump fall, PLUS new Q waves / new LBBB / new occlusion / new RWMA, AND no STE (this engine is NSTEMI variant). Three drivers to discriminate: early graft thrombosis (focal RWMA + culprit), distal embolization / incomplete revasc (diffuse), or type-2 peri-op demand ischemia (anemia, hypotension, AF/RVR, sepsis)
    inputs: troponin_baseline_and_serial, ecg_serial, cabg_operative_details
    advance: UDMI Type 5 NSTEMI confirmed + driver hypothesis framed
  2. 2ENTRY
    Triage with serial 0/1-h hsTn pattern interpretation (re-rise vs plateau), repeat ECG, bedside echo with baseline comparison; CT-surgery and cardiology consult both bedside within 1 h; defer empiric DAPT/UFH escalation pending bleed-risk and CT-surg clearance
    inputs: age
    advance: Pathway started + dual surgery+cardiology consult initiated
  3. 3CONTEXT
    Catalogue peri-op course (pump time, cardioplegia, intra-op events, post-op AF, anemia trend, BP support need, vasoplegia), current meds, chest-tube output, sternal status, baseline echo / pre-op cath films
    inputs: hgb_baseline, creatinine_egfr, hr, current_post_cabg_meds
    advance: Peri-op + bleed context complete
  4. 4RED_FLAGS
    Cardiogenic shock (SCAI B+) → emergent cath + MCS team; tamponade (sternotomy adhesion masks classic signs — relies on echo + clinical); active chest-tube bleed or sternal dehiscence → bleed-control bundle + CT-surg priority; ongoing ischemia despite trigger correction → emergent cath regardless of bleed risk
    inputs: sbp, chest_tube_output_and_sternal_status
    actions: cardiogenic_shock
    advance: Red flags screened + escalation triggers documented
  5. 5INITIAL_WORKUP
    Serial 0/1-h hsTn (interpret kinetics: re-rise vs plateau), serial ECG, echo with pre-op + immediate post-op comparison (UDMI imaging criterion); BMP, CBC (Hgb + plt), coags, lactate (peri-op shock screen), CXR for mediastinal width / effusion / sternal wires alignment; pull pre-op cath films + operative report
    inputs: troponin_baseline_and_serial, ecg_serial, echo_with_baseline_comparison, hgb_baseline, creatinine_egfr
    actions: acs_pathway, panel.cardiac, panel.renal, panel.cbc
    advance: Diagnostic workup complete + UDMI Type 5 criteria scored
  6. 6BRANCHING_WORKUP
    If ongoing ischemia, hemodynamic instability, new RWMA, or sustained trop rise → emergent cath with full graft + native angiography (mandatory in post-CABG); SVG culprit → embolic protection device per SAFER (PMID 11815441) before intervention; native PCI of distal anastomotic territory preferred when graft anatomy unfavorable. If type-2 demand suspect (clear extracardiac trigger + slow trop plateau) → trigger-targeted therapy first, defer cath, repeat trop and ECG
    actions: chest_pain
    advance: Cath strategy executed OR trigger-targeted plan started + reassessment cadence set
  7. 7DIFFERENTIAL
    UDMI Type 5 NSTEMI sub-classification: (1) early graft thrombosis (focal RWMA + culprit on cath), (2) distal embolization / incomplete revasc (diffuse, often non-territorial), (3) type-2 peri-op demand ischemia (clear extracardiac trigger + slow plateau); pericarditis post-pump can mimic; PE post-op also in differential
    advance: Driver classified; downstream regimen aligned
  8. 8RISK_STRATIFICATION
    HEART score in post-CABG window biased by prior CAD; SCAI 2022 CS staging if hemodynamics unstable; SOFA if multi-organ dysfunction (post-pump renal, hepatic, hematologic); CKD-EPI for contrast + DOAC dosing; CHA2DS2-VASc if AF detected — drives long-term AC + DAPT triple-therapy decisions
    inputs: age, sbp, creatinine_egfr, troponin_baseline_and_serial
    actions: calc.heart, calc.sofa, calc.ckd_epi_2021, calc.cha2ds2vasc, calc.map
    advance: Risk stratification documented
  9. 9TREATMENT
    Driver-targeted: (1) early graft thrombosis confirmed → PCI of graft (embolic protection if SVG) OR native distal PCI when feasible — redo CABG generally avoided in first 30 d unless multivessel + multi-graft failure; (2) type-2 demand → optimize Hgb to >9 (lower threshold than TRICS-III restrictive given MI), correct BP/AF/sepsis trigger, conservative anti-thrombotic; (3) distal embolization → optimal medical therapy + surveillance. Anti-thrombotic decision MUST be coordinated with CT-surgery: most patients already on ASA + clopidogrel; escalation to ticagrelor or P2Y12 reload requires bleed assessment + chest-tube output trend. UFH only after CT-surg clearance + chest tubes <100 mL/h
    inputs: creatinine_egfr, hgb_baseline
    actions: protocol.stemi
    advance: Driver-aligned regimen + CT-surg-cleared anti-thrombotic plan documented
  10. 10DISPOSITION
    CICU vs CTICU based on hemodynamics + chest tube status; cardiology + cardiac surgery dual ownership; lower threshold for ICU than typical NSTEMI given peri-op complexity
    advance: Unit + dual-service ownership documented
  11. 11MONITORING
    Telemetry; serial trop to confirm trigger correction normalises trend; daily ECG + echo at 5-7 d for thrombus + LV function reassessment; chest tube + sternal exam each shift; renal trajectory (CIN-AKI surveillance); AF surveillance (POAF up to 30-40% incidence)
    inputs: hgb_baseline, creatinine_egfr
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders + reassessment cadence documented
  12. 12FOLLOWUP
    Cardiology + CT-surgery joint follow-up at 1, 4, 12 wks; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab Class I per ACC/AHA 2025; intensified secondary prevention (high-intensity statin lifelong, BP <130/80, no smoking, GDMT if EF reduced); DAPT-duration plan per POPULAR-CABG (PMID 34016267)
    advance: Long-term joint follow-up + cardiac rehab booked