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cardio.ascvd.chronic.v1PRODUCTION
cardio.ascvd.chronic.v1

Chronic coronary / ASCVD secondary prevention

cardiologychronicadult
Hard-required inputs
0 / 4
Care setting:

Encounter flow

8/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm chronic CCD/ASCVD scope; acute chest pain → cardio.stemi.core.v1 (ACC/AHA 2022)

Inputs
0
Actions
0
Advance rule
Set
Advance when

patient is stable, secondary prevention focus

Patient inputs (12)

PREVENT calculator + drug tolerability (ACC/AHA 2022)

BP target <130/80 in CCD per 2025 HTN

Statin/DOAC dosing, COMPASS rivaroxaban renal cutoff (ACC/AHA 2022)

Target <55 very-high risk; <70 high risk per 2026 Lipid

DAPT duration + intensification post-ACS (ACC/AHA 2022)

DAPT timing, antiplatelet agent selection (ACC/AHA 2022)

COMPASS regimen rivaroxaban 2.5 BID + ASA (ACC/AHA 2022)

Existing statin/antiplatelet — escalation vs initiation (ACC/AHA 2022)

Glycemic control + SGLT2/GLP-1 in DM-ASCVD (ACC/AHA 2022)

2026 universal Lp(a) screening Class 1

Non-HDL/ApoB for residual risk (ACC/AHA 2022)

DAPT bleed risk + extended therapy decision (ACC/AHA 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationalsevererecurrent_acs
    New chest pain / ECG change / troponin rise in CCD patient (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateldl_above_55_very_high_risk
    LDL-C ≥55 mg/dL (or non-HDL-C ≥85) in established-ASCVD patient on max-tolerated statin + ezetimibe — residual-cholesterol phenotype (2026 ACC/AHA, PMID 41824590)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateresidual_inflammatory_risk_hscrp
    hsCRP ≥2 mg/L on optimised statin in established CCD/post-MI — residual-inflammatory phenotype
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebp_above_130_80_ccd
    BP ≥130/80 in CCD patient at clinic visits and home BP (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedm_a1c_above_7_with_ascvd
    A1c >7 with ASCVD (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepad_leg_symptoms
    Claudication or rest pain with ABI <0.9 (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaspirin_intolerant_or_high_bleed
    GI bleed on ASA / very high HAS-BLED (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpost_mi_ef_preserved_bb_reassessment
    Post-MI patient with LVEF ≥50% on a β-blocker without other indication (HF/angina/arrhythmia) — REDUCE-AMI reassessment
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

2023 AHA/ACC CCD + 2026 Dyslipidemia — secondary-prevention bundle (5 pillars, stepwise)
axis: ascvd_secondary_prevention_bundlestep 1 - Step 1 — Antiplatelet / antithrombotic
Selected step "Step 1 — Antiplatelet / antithrombotic" — Established ASCVD (2023 CCD Class I, PMID 37471501)
  • aspirin
    first line
    antiplatelet_COX1
    81 mg • PO • once daily
    triggers: established_ASCVD
    SAPT cornerstone — irreversible COX-1/TxA2 platelet inhibition ~95%, steady-state 5–7 d; ATT secondary-prevention serious-vascular-event ↓~20%. Lifelong unless a defined DAPT/DPI window (2023 CCD Class I, PMID 37471501)
    rxcui 1191
  • clopidogrel
    add on
    P2Y12_inhibitor
    75 mg • PO • once daily
    triggers: recent_PCI, recent_ACS, aspirin_intolerant
    DAPT × 6–12 mo post-PCI; P2Y12 ~40–60% inhibition (CYP2C19-dependent), onset 2 h with 300–600 mg load. As SAPT monotherapy when ASA-intolerant: CAPRIE composite RRR 8.7% (95% CI 0.3–16.5) vs ASA (PMID 8918275)
    rxcui 32968
  • ticagrelor
    add on
    P2Y12_inhibitor
    60 mg BID (extended DAPT) or 90 mg BID (≤1 y post-ACS) • PO • BID
    triggers: high_risk_post_MI, recent_ACS
    Reversible P2Y12 ~80–90% inhibition, onset 30 min–2 h. PEGASUS-TIMI 54 60 mg BID beyond 1 y: CV death/MI/stroke HR 0.84 (0.74–0.95), TIMI major bleed 2.30 vs 1.06% (PMID 25773268)
    rxcui 1116632
  • prasugrel
    add on
    P2Y12_inhibitor
    10 mg (5 mg if <60 kg or ≥75 y) • PO • once daily
    triggers: post_PCI_ACS, no_prior_stroke_TIA
    Irreversible P2Y12 ~80% inhibition; post-PCI ACS DAPT. Contraindicated with prior stroke/TIA (net-harm signal)
    rxcui 613391
  • rivaroxaban
    add on
    DOAC_FXa_low_dose
    2.5 mg BID + ASA 81 mg • PO • BID
    triggers: stable_CAD_or_PAD, no_high_bleed_risk, CrCl_ge_15
    COMPASS dual-pathway (vascular dose): MI/stroke/CV death HR 0.74 (0.65–0.86), all-cause death HR 0.77 (0.65–0.90), major bleed HR 1.66 (1.37–2.03) vs ASA alone (PMID 29132879)
    rxcui 1114195

outpatient playbook — drug actions (6)

  1. 1. aspirin 81 mg
    81 mg • PO • daily
    trigger: Established ASCVD (ACC/AHA 2022)
    Lifelong (ACC/AHA 2022)
  2. 2. high-intensity statin + ezetimibe
    Atorvastatin 80 + ezetimibe 10 • PO • daily
    trigger: LDL >55 (ACC/AHA 2022)
    IMPROVE-IT (ACC/AHA 2022)
  3. 3. PCSK9i if LDL >55 on statin + ezetimibe
    Evolocumab 140 mg q2w • SC • q2w
    trigger: LDL above goal (ACC/AHA 2022)
    FOURIER (ACC/AHA 2022)
  4. 4. ACEi/ARB + BB if EF <40 / recent MI
    Lisinopril 10-40 mg + metoprolol succinate 25-200 mg • PO • daily
    trigger: LV dysfunction or post-MI (ACC/AHA 2022)
    HOPE / CAPRICORN (ACC/AHA 2022)
  5. 5. SGLT2i + GLP-1 in DM
    Empagliflozin 10 mg + semaglutide 0.25 mg weekly titrated • PO + SC • daily / weekly
    trigger: DM + ASCVD (ACC/AHA 2022)
    EMPA-REG / SELECT (ACC/AHA 2022)
  6. 6. COMPASS rivaroxaban 2.5 BID + ASA in stable CAD/PAD
    2.5 mg BID + ASA 81 • PO • BID
    trigger: Stable CAD or PAD with low bleed risk + CrCl >15 (ACC/AHA 2022)
    COMPASS (ACC/AHA 2022)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Prior MI / PCI / CABG (ACC/AHA 2022); Stable angina / chronic coronary syndrome (ACC/AHA 2022); PAD or carotid disease (ASCVD broader) (ACC/AHA 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic coronary / ASCVD secondary prevention** (cardio.ascvd.chronic.v1).
Scope: Confirm chronic CCD/ASCVD scope; acute chest pain → cardio.stemi.core.v1 (ACC/AHA 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **2023 AHA/ACC CCD + 2026 Dyslipidemia — secondary-prevention bundle (5 pillars, stepwise)** — step "Step 1 — Antiplatelet / antithrombotic".
1. aspirin 81 mg PO once daily (antiplatelet_COX1, first line) — SAPT cornerstone — irreversible COX-1/TxA2 platelet inhibition ~95%, steady-state 5–7 d; ATT secondary-prevention serious-vascular-event ↓~20%. Lifelong unless a defined DAPT/DPI window (2023 CCD Class I, PMID 37471501)
2. clopidogrel 75 mg PO once daily (P2Y12_inhibitor, add on) — DAPT × 6–12 mo post-PCI; P2Y12 ~40–60% inhibition (CYP2C19-dependent), onset 2 h with 300–600 mg load. As SAPT monotherapy when ASA-intolerant: CAPRIE composite RRR 8.7% (95% CI 0.3–16.5) vs ASA (PMID 8918275)
3. ticagrelor 60 mg BID (extended DAPT) or 90 mg BID (≤1 y post-ACS) PO BID (P2Y12_inhibitor, add on) — Reversible P2Y12 ~80–90% inhibition, onset 30 min–2 h. PEGASUS-TIMI 54 60 mg BID beyond 1 y: CV death/MI/stroke HR 0.84 (0.74–0.95), TIMI major bleed 2.30 vs 1.06% (PMID 25773268)
4. prasugrel 10 mg (5 mg if <60 kg or ≥75 y) PO once daily (P2Y12_inhibitor, add on) — Irreversible P2Y12 ~80% inhibition; post-PCI ACS DAPT. Contraindicated with prior stroke/TIA (net-harm signal)
5. rivaroxaban 2.5 mg BID + ASA 81 mg PO BID (DOAC_FXa_low_dose, add on) — COMPASS dual-pathway (vascular dose): MI/stroke/CV death HR 0.74 (0.65–0.86), all-cause death HR 0.77 (0.65–0.90), major bleed HR 1.66 (1.37–2.03) vs ASA alone (PMID 29132879)

Setting playbook (outpatient) — Maintain all 5 secondary-prevention pillars at goal; identify gaps annually; integrate cardiometabolic comorbidity therapies (DM/HF) (ACC/AHA 2022)
6. aspirin 81 mg 81 mg PO daily — Established ASCVD (ACC/AHA 2022) (Lifelong (ACC/AHA 2022))
7. high-intensity statin + ezetimibe Atorvastatin 80 + ezetimibe 10 PO daily — LDL >55 (ACC/AHA 2022) (IMPROVE-IT (ACC/AHA 2022))
8. PCSK9i if LDL >55 on statin + ezetimibe Evolocumab 140 mg q2w SC q2w — LDL above goal (ACC/AHA 2022) (FOURIER (ACC/AHA 2022))
9. ACEi/ARB + BB if EF <40 / recent MI Lisinopril 10-40 mg + metoprolol succinate 25-200 mg PO daily — LV dysfunction or post-MI (ACC/AHA 2022) (HOPE / CAPRICORN (ACC/AHA 2022))
10. SGLT2i + GLP-1 in DM Empagliflozin 10 mg + semaglutide 0.25 mg weekly titrated PO + SC daily / weekly — DM + ASCVD (ACC/AHA 2022) (EMPA-REG / SELECT (ACC/AHA 2022))
11. COMPASS rivaroxaban 2.5 BID + ASA in stable CAD/PAD 2.5 mg BID + ASA 81 PO BID — Stable CAD or PAD with low bleed risk + CrCl >15 (ACC/AHA 2022) (COMPASS (ACC/AHA 2022))

Non-pharmacologic actions:
- Cardiac rehabilitation (Class I)
- Mediterranean / DASH diet (ACC/AHA 2022)
- 150 min/week aerobic + resistance (ACC/AHA 2022)
- Smoking cessation pharmacotherapy (ACC/AHA 2022)
- Annual flu + pneumococcal + COVID + RSV (ACC/AHA 2022)
- AAA screening if eligible (ACC/AHA 2022)
- Sleep apnoea screen (ACC/AHA 2022)

AVOID / contraindication checks:
- DAPT_avoid_high_bleed_risk — 2023 CCD (PMID 37471501)
- DPI_rivaroxaban_avoid_high_bleed_or_CrCl_below_15 — COMPASS exclusion (PMID 29132879)
- Prasugrel_avoid_prior_stroke_TIA — net harm signal
- ACEi_ARB_avoid_pregnancy — 2023 CCD Class III
- Beta_blocker_avoid_decompensated_HF_or_high_grade_AV_block — 2023 CCD
- Beta_blocker_deescalate_if_post_MI_EF_preserved — REDUCE AMI (PMID 38587241)
- Colchicine_avoid_eGFR_below_30_or_strong_CYP3A4_Pgp_inhibitor — COLCOT/LoDoCo2 dosing
- Icosapent_caution_AF_and_bleeding — REDUCE IT (PMID 30415628)
- GLP1_avoid_personal_family_MTC_MEN2 — label
- SGLT2_hold_periprocedural_NPO_DKA_risk — 2023 CCD

Monitoring

Regimen monitoring:
- lipid panel 4-12wk post-change then q3-12 months (2026 ACC/AHA PMID 41824590)
- BMP q3-6 months (2023 CCD PMID 37471501)
- A1c q3-6 months in DM (ADA SoC 2026)
- BP at each visit target below 130 80 (2025 HBP PMID 40811516)
- CK/LFT with statin only if symptomatic (2026 ACC/AHA)
- cardiac rehab completion (Cochrane CR PMID 34741536)

Setting (outpatient) monitoring:
- Lipid + BP + A1c + BMP cadence per pillars (ACC/AHA 2022)
- Adherence assessment (ACC/AHA 2022)
- Symptom-driven workup if recurrent angina (ACC/AHA 2022)

Follow-up plan: Cardiac rehab referral, vaccination (flu/pneumococcal/COVID), lifestyle, AAA screening if eligible (ACC/AHA 2022)
- Close-out criterion: follow-up + adjunctive prevention plan in place

Monitoring phase: Lipid 4–12 wks post-change then q3–12 mo; LFT/CK with statin only if symptomatic; A1c q3–6 mo; BP at each visit (ACC/AHA 2022)

Disposition

Current setting: outpatient — Maintain all 5 secondary-prevention pillars at goal; identify gaps annually; integrate cardiometabolic comorbidity therapies (DM/HF) (ACC/AHA 2022)

Disposition criteria:
- At goal across pillars → q6–12 month visits (ACC/AHA 2022)
- Gaps → q3 month visits until optimised (ACC/AHA 2022)

Escalation triggers (move to higher acuity):
- Recurrent angina / equivalent → calc.heart triage; consider repeat angiography (ACC/AHA 2022)
- Acute chest pain → ED + STEMI engine (ACC/AHA 2022)
- New HF symptoms → echo + HF engine (ACC/AHA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] New chest pain / ECG change / troponin rise in CCD patient (ACC/AHA 2022)
- [MODERATE] LDL-C ≥55 mg/dL (or non-HDL-C ≥85) in established-ASCVD patient on max-tolerated statin + ezetimibe — residual-cholesterol phenotype (2026 ACC/AHA, PMID 41824590)
- [MODERATE] hsCRP ≥2 mg/L on optimised statin in established CCD/post-MI — residual-inflammatory phenotype

Citations

- 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline (PMID 37471501, DOI 10.1161/CIR.0000000000001168) + 2026 ACC/AHA Multisociety Dyslipidemia Guideline (PMID 41824590/41824552) + 2019 AHA/ACC Primary Prevention (PMID 31613350) + 2025 AHA/ACC HBP + ADA SoC 2026 [PMID:37471501](https://pubmed.ncbi.nlm.nih.gov/37471501/)
- Cited evidence (PMID 41824590) [PMID:41824590](https://pubmed.ncbi.nlm.nih.gov/41824590/)
- Cited evidence (PMID 41824552) [PMID:41824552](https://pubmed.ncbi.nlm.nih.gov/41824552/)
- Cited evidence (PMID 8918275) [PMID:8918275](https://pubmed.ncbi.nlm.nih.gov/8918275/)
- Cited evidence (PMID 25773268) [PMID:25773268](https://pubmed.ncbi.nlm.nih.gov/25773268/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline (PMID 37471501, DOI 10.1161/CIR.0000000000001168) + 2026 ACC/AHA Multisociety Dyslipidemia Guideline (PMID 41824590/41824552) + 2019 AHA/ACC Primary Prevention (PMID 31613350) + 2025 AHA/ACC HBP + ADA SoC 2026 — PMID:37471501
  • Cited evidence (PMID 41824590) — PMID:41824590
  • Cited evidence (PMID 41824552) — PMID:41824552
  • Cited evidence (PMID 8918275) — PMID:8918275
  • Cited evidence (PMID 25773268) — PMID:25773268