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cardio.nstemi.cancer-active.v1PRODUCTION
cardio.nstemi.cancer-active.v1

NSTEMI in active-cancer patient (cardio-oncology bleeding-risk balance)

cardiologyacuteadult
Hard-required inputs
0 / 19
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm NSTE-ACS in active-cancer patient — key first decisions: (1) type-1 vs type-2 NSTEMI? (2) ICI myocarditis differential? (3) bleeding-risk burden (CIT, tumor anatomy, recent bleed)? (4) prognosis estimate from oncology? Inherit core NSTEMI workflow via routing, modify per cancer-specific axes

Inputs
2
Actions
0
Advance rule
Set
Advance when

NSTEMI confirmed + cancer context characterized + ICI myocarditis ruled in/out

Patient inputs (20)

EF (anthracycline cardiomyopathy assessment), RWMA (regional ischemia), pericardial effusion (paraneoplastic, radiation), valvular (radiation valvulopathy)

Older cancer patients have higher bleeding risk + worse cardiac prognosis; informs DAPT duration + cath decision

Drug dosing — LMWH renal-adjusted; chemotherapy weight-based dosing review

Tumor type + stage drives bleeding risk (GI/GU/intracranial high) + cardiotoxic chemotherapy + radiation history; prognosis estimates inform invasive vs conservative strategy

Specific agents drive ACS presentation: 5-FU/capecitabine = vasospasm; anthracycline = cardiomyopathy; ICI = myocarditis; VEGF inhibitor = HTN + thrombosis; tamoxifen = thrombosis; trastuzumab = HF; informs both pathophysiology + management

Life expectancy >6 mo + reasonable functional status → invasive strategy with shared decision; <3 mo or palliative intent → conservative medical management; cardio-oncology partnership essential

Tumor bleeding (GI/GU/intracranial), procedural bleeding, mucositis from chemo — drives antithrombotic decision

Recurrent ACS shifts urgency; stent thrombosis differential

Hypotension = high-risk per GRACE; affects β-blocker / nitrate use

Tachycardia / bradycardia limit β-blocker; AF detection (cancer + chemo predispose to AF)

0/1-h or 0/3-h ESC 2023 algorithm; rise/fall confirms NSTEMI; baseline + serial trending essential to distinguish type-1 from type-2

Cancer-AKI (chemo-AKI, paraprotein nephropathy, tumor lysis), contrast nephropathy risk; affects all renal-cleared drug dosing + cath strategy

Platelets primary — chemotherapy-induced thrombocytopenia (CIT) primary driver of bleeding-risk decision; <50K precludes most antithrombotics; <100K shortens DAPT to 1–3 mo per MASTER DAPT philosophy; absolute neutrophil count screens for neutropenic state

Cancer coagulopathy + DIC differential; baseline before AC

Statin titration target LDL <70 / <55 in very-high-risk

Hepatic dysfunction common in cancer (mets, paraneoplastic, hepatotoxic agents); affects clopidogrel + ticagrelor + statin dosing

Dynamic changes = high-risk; rule out STEMI; QTc surveillance for cancer treatment QT effects

Pulmonary edema, pleural effusion (paraneoplastic / mets), radiation pneumonitis, mediastinal mass / nodes

Oxygen only if SpO2 <90%; cancer pulmonary disease + radiation pneumonitis common

ICI myocarditis differential — late gadolinium enhancement + edema patterns; biopsy if dx uncertain (Mahmood 2018 PMID 30013321)

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningtumor_bleeding_precluding_dapt
    Active tumor bleeding (GI/GU/intracranial/pulmonary cavity) precluding standard DAPT in cancer NSTEMI patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningici_myocarditis_with_pump_or_conduction_failure
    ICI myocarditis with new severe LV dysfunction OR new conduction abnormality (AV block, BBB) in patient on ICI within last 30–60 d
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethrombocytopenia_below_50k_precluding_anticoagulation
    Platelets <50K in cancer NSTEMI patient — precludes most antithrombotics; requires shared decision re: ASA continuation, P2Y12 hold, parenteral AC hold, and cath strategy modification
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecontrast_induced_aki_in_cancer_patient
    Cancer patient developing AKI after contrast — chemo-AKI + paraprotein nephropathy + tumor lysis predispose; KDIGO Stage 1+ AKI within 48–72h of contrast exposure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereend_of_life_with_palliative_intent_during_acs
    Cancer NSTEMI in patient with end-stage cancer (life expectancy <3 mo) or palliative intent — invasive strategy and aggressive antithrombotic generally inappropriate
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Active-cancer NSTEMI — high-bleeding-risk antithrombotic with shortened DAPT, conservative-vs-invasive shared decision, statin continued, BB per EF + chemo plan, ICI myocarditis steroids if indicated (ESC cardio-onc 2022 + ACC/AHA 2025 + MASTER DAPT)
axis: cancer_active_nstemi_phenotype
Selected axis "Active-cancer NSTEMI — high-bleeding-risk antithrombotic with shortened DAPT, conservative-vs-invasive shared decision, statin continued, BB per EF + chemo plan, ICI myocarditis steroids if indicated (ESC cardio-onc 2022 + ACC/AHA 2025 + MASTER DAPT)" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162–325 mg load if not on ASA → 81 mg daily • PO • load + 81 mg daily long-term
    triggers: cancer_nstemi_with_platelets_above_50k
    ACC/AHA 2025 Class I; continued in nearly all cancer NSTEMI patients with platelets >50K
    rxcui 1191
  • clopidogrel
    first line
    p2y12_inhibitor
    300–600 mg load → 75 mg daily • PO • daily × 3–6 mo per high-bleeding-risk modification
    triggers: cancer_nstemi_with_pci_performed
    Preferred over ticagrelor/prasugrel in cancer because of better bleeding profile + drug interaction tolerability; 3–6 mo DAPT per MASTER DAPT PMID 34516952 + ESC cardio-onc 2022 §6.4
    rxcui 309362
  • ticagrelor
    second line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 3–6 mo per high-bleeding-risk modification
    triggers: cancer_nstemi_with_pci_and_no_intracranial_or_recent_bleed
    PLATO PMID 19717846; superior to clopidogrel for ischemic events but higher bleeding; AVOID if active intracranial mass or recent bleed; can de-escalate to ticagrelor monotherapy after 3 mo per TWILIGHT PMID 31475798
    rxcui 1116632
  • unfractionated_heparin
    first line
    parenteral_anticoagulant
    60 U/kg bolus (max 4000) → 12 U/kg/h infusion • IV • continuous, aPTT 1.5–2× control × 24h post-PCI
    triggers: cancer_nstemi_pci_planned_with_platelets_above_50k
    ACC/AHA 2025 Class I parenteral AC; preferred over LMWH in cancer due to reversibility + renal-friendly + no accumulation
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily
    triggers: cancer_nstemi_with_acceptable_lfts
    PROVE-IT PMID 15007110; multiple cardio-oncology registries show benefit + low toxicity in cancer; reduce to 40 mg if hepatic dysfunction
    rxcui 83367
  • carvedilol
    first line
    mixed_alpha_beta_blocker
    3.125 mg BID titrate to 25 mg BID • PO • BID
    triggers: cancer_nstemi_with_ef_below_40, concurrent_anthracycline_chemotherapy_for_cardioprotection
    COPERNICUS PMID 11386262 + PRADA Lancet 2018 PMID 26656872 — carvedilol may protect from anthracycline cardiotoxicity in active chemotherapy
    rxcui 20352
  • sacubitril-valsartan
    first line
    arni
    24/26 BID titrate to 97/103 BID • PO • BID
    triggers: cancer_nstemi_with_ef_below_40_after_acei_washout
    PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF — start once EF <40 + euvolemia + SBP ≥100 + ≥36h post-ACEi
    rxcui 1656328
  • methylprednisolone
    first line
    corticosteroid_immunosuppressant
    1–2 mg/kg/d IV • IV • daily × 3–5 d then PO prednisone taper
    triggers: ici_myocarditis_confirmed_or_strongly_suspected
    Mahmood NEJM 2018 PMID 30013321 + ASCO 2018 ICI cardiotoxicity guideline — high-dose corticosteroid first-line for ICI myocarditis; consider additional immunosuppression (mycophenolate, tacrolimus, infliximab) for refractory cases
    rxcui 6902
  • verapamil
    add on
    non_dihydropyridine_ccb
    80–120 mg PO TID • PO • TID
    triggers: 5_fu_or_capecitabine_induced_coronary_vasospasm
    Discontinue offending fluoropyrimidine + use CCB to relieve coronary vasospasm in 5-FU/capecitabine cardiotoxicity
    rxcui 11170
  • apixaban
    comorbidity specific
    doac_factor_xa_direct
    5 mg BID (or 2.5 mg per dose-reduction criteria) • PO • BID
    triggers: cancer_associated_thrombosis_with_concurrent_acs, af_with_cancer_nstemi
    Khorana NEJM 2019 — apixaban shown effective in cancer-associated thrombosis; use with caution + low-dose ASA (NOT triple therapy if avoidable) per ESC cardio-onc 2022
    rxcui 1364430

outpatient playbook — drug actions (3)

  1. 1. ASA monotherapy long-term post-DAPT
    rxcui 1191
    81 mg daily • PO • daily
    trigger: completion of 3–6 mo DAPT
    TWILIGHT PMID 31475798 + ACC/AHA 2025
  2. 2. continue statin long-term
    rxcui 83367
    40–80 mg daily • PO • daily
    trigger: post-MI
    AHA 2018 lipid + cardio-onc consensus
  3. 3. continue HF regimen if HFrEF
    rxcui 20352
    carvedilol + ARNI + MRA + SGLT2i max tolerated • PO • as scheduled
    trigger: HFrEF
    ACC/AHA 2022 HF 4-pillar

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: NSTE-ACS pattern in patient with active malignancy (currently on chemo/radiation/immunotherapy/targeted therapy or within 6 mo of completion); hsTn rise in cancer patient with platelets <100K — high-bleeding-risk antithrombotic decision; Chest pain in cancer patient with anemia / infection / dehydration / hypoxemia / severe pain — type-2 NSTEMI candidate (4th UDMI PMID 30153967).

Objective

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

Assessment

**NSTEMI in active-cancer patient (cardio-oncology bleeding-risk balance)** (cardio.nstemi.cancer-active.v1).
Phenotype framing: Type-1 plaque-rupture NSTEMI (standard ACS regimen modified) vs type-2 demand-mismatch NSTEMI (correct trigger primarily) vs ICI myocarditis (steroids) vs 5-FU/capecitabine vasospasm (CCB + discontinue agent) vs radiation coronary disease (often distal LAD/LM ostia, diffuse pattern) vs anthracycline cardiomyopathy with secondary ischemia vs paraneoplastic / coagulopathy-driven vs pericarditis from radiation/mets
Scope: Confirm NSTE-ACS in active-cancer patient — key first decisions: (1) type-1 vs type-2 NSTEMI? (2) ICI myocarditis differential? (3) bleeding-risk burden (CIT, tumor anatomy, recent bleed)? (4) prognosis estimate from oncology? Inherit core NSTEMI workflow via routing, modify per cancer-specific axes

No severity triggers fired against current inputs.

Plan

Regimen axis: **Active-cancer NSTEMI — high-bleeding-risk antithrombotic with shortened DAPT, conservative-vs-invasive shared decision, statin continued, BB per EF + chemo plan, ICI myocarditis steroids if indicated (ESC cardio-onc 2022 + ACC/AHA 2025 + MASTER DAPT)**.
1. aspirin 162–325 mg load if not on ASA → 81 mg daily PO load + 81 mg daily long-term (antiplatelet_cox1, first line) — ACC/AHA 2025 Class I; continued in nearly all cancer NSTEMI patients with platelets >50K
2. clopidogrel 300–600 mg load → 75 mg daily PO daily × 3–6 mo per high-bleeding-risk modification (p2y12_inhibitor, first line) — Preferred over ticagrelor/prasugrel in cancer because of better bleeding profile + drug interaction tolerability; 3–6 mo DAPT per MASTER DAPT PMID 34516952 + ESC cardio-onc 2022 §6.4
3. ticagrelor 180 mg load → 90 mg BID PO BID × 3–6 mo per high-bleeding-risk modification (p2y12_inhibitor, second line) — PLATO PMID 19717846; superior to clopidogrel for ischemic events but higher bleeding; AVOID if active intracranial mass or recent bleed; can de-escalate to ticagrelor monotherapy after 3 mo per TWILIGHT PMID 31475798
4. unfractionated_heparin 60 U/kg bolus (max 4000) → 12 U/kg/h infusion IV continuous, aPTT 1.5–2× control × 24h post-PCI (parenteral_anticoagulant, first line) — ACC/AHA 2025 Class I parenteral AC; preferred over LMWH in cancer due to reversibility + renal-friendly + no accumulation
5. atorvastatin 80 mg PO daily (statin_high_intensity, first line) — PROVE-IT PMID 15007110; multiple cardio-oncology registries show benefit + low toxicity in cancer; reduce to 40 mg if hepatic dysfunction
6. carvedilol 3.125 mg BID titrate to 25 mg BID PO BID (mixed_alpha_beta_blocker, first line) — COPERNICUS PMID 11386262 + PRADA Lancet 2018 PMID 26656872 — carvedilol may protect from anthracycline cardiotoxicity in active chemotherapy
7. sacubitril-valsartan 24/26 BID titrate to 97/103 BID PO BID (arni, first line) — PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF — start once EF <40 + euvolemia + SBP ≥100 + ≥36h post-ACEi
8. methylprednisolone 1–2 mg/kg/d IV IV daily × 3–5 d then PO prednisone taper (corticosteroid_immunosuppressant, first line) — Mahmood NEJM 2018 PMID 30013321 + ASCO 2018 ICI cardiotoxicity guideline — high-dose corticosteroid first-line for ICI myocarditis; consider additional immunosuppression (mycophenolate, tacrolimus, infliximab) for refractory cases
9. verapamil 80–120 mg PO TID PO TID (non_dihydropyridine_ccb, add on) — Discontinue offending fluoropyrimidine + use CCB to relieve coronary vasospasm in 5-FU/capecitabine cardiotoxicity
10. apixaban 5 mg BID (or 2.5 mg per dose-reduction criteria) PO BID (doac_factor_xa_direct, comorbidity specific) — Khorana NEJM 2019 — apixaban shown effective in cancer-associated thrombosis; use with caution + low-dose ASA (NOT triple therapy if avoidable) per ESC cardio-onc 2022

Setting playbook (outpatient) — Long-term cardio-oncology + cardiology + oncology surveillance; chronic management of post-MI HF if applicable; long-term mental health; transition from active cancer treatment to survivorship + cardio-onc surveillance for late effects (late-onset anthracycline cardiomyopathy, radiation valvulopathy)
11. ASA monotherapy long-term post-DAPT 81 mg daily PO daily — completion of 3–6 mo DAPT (TWILIGHT PMID 31475798 + ACC/AHA 2025)
12. continue statin long-term 40–80 mg daily PO daily — post-MI (AHA 2018 lipid + cardio-onc consensus)
13. continue HF regimen if HFrEF carvedilol + ARNI + MRA + SGLT2i max tolerated PO as scheduled — HFrEF (ACC/AHA 2022 HF 4-pillar)

Non-pharmacologic actions:
- Cardio-onc clinic quarterly
- Cancer survivorship care plan integration
- Mental health long-term
- Cardiac rehab maintenance phase
- Family CPR/AED maintenance

AVOID / contraindication checks:
- Antithrombotic_AVOID_if_platelets_below_30K (SCAI 2019 high bleeding risk)
- Dapt_shortened_to_1_to_3_mo_if_platelets_30_to_50k_per_master_dapt (PMID 34516952)
- Prasugrel_AVOID_in_active_intracranial_mass_or_recent_bleed (TRITON TIMI 38)
- Ticagrelor_AVOID_in_active_intracranial_mass_or_recent_bleed (PLATO)
- Lmwh_AVOID_in_severe_renal_impairment_or_use_ufh_instead (KDIGO + ACCP)
- Ici_continuation_AVOID_after_severe_myocarditis (ASCO 2018 ICI cardiotox)
- 5_fu_or_capecitabine_DISCONTINUE_if_vasospasm_acs (oncology consensus)
- High_dose_dose_intensity_chemotherapy_AVOID_during_acs_acute_phase (cardio onc consensus)

Monitoring

Regimen monitoring:
- cbc q1 to 2 days x first week for cit trajectory (cardio-onc consensus)
- platelet count threshold review at each dapt decision (MASTER DAPT)
- serial hstn per esc 2023 (PMID 37622670)
- ecg with qtc daily if chemo continuing (ESC cardio-onc 2022)
- kccq at 7d for hf assessment
- cardiac mri at 3 to 6 mo post ici myocarditis (Mahmood 2018)
- echocardiography at 3 mo post acs for lvef reassessment (ACC/AHA 2025)
- lfts q3 mo on statin (FDA label + ACC/AHA 2018 lipid)
- serial creatinine q24h on ac and post contrast (KDIGO 2026)

Setting (outpatient) monitoring:
- Quarterly cardio-onc visits
- Annual labs + ECG + echo
- Long-term cancer surveillance per oncology

Follow-up plan: Cardio-oncology clinic follow-up at 1 wk + 4 wk; oncology continuation decision re: chemotherapy hold/dose modification; cardiology long-term for any post-MI HF; mental health (cancer + cardiac dual-burden very high); palliative care if indicated; patient/family GOC re: future ICU + interventional escalation; primary care for medication reconciliation
- Close-out criterion: cardio-onc + oncology + palliative care + mental health follow-up booked

Monitoring phase: Continuous ECG + SpO2; repeat hsTn per 0/1-h pathway; CBC daily for CIT trajectory; bleeding signs per BARC 2011; QTc surveillance daily if methadone or QT-prolonging chemotherapy; KCCQ at 7 d if HF concern

Disposition

Current setting: outpatient — Long-term cardio-oncology + cardiology + oncology surveillance; chronic management of post-MI HF if applicable; long-term mental health; transition from active cancer treatment to survivorship + cardio-onc surveillance for late effects (late-onset anthracycline cardiomyopathy, radiation valvulopathy)

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists; cancer survivorship + cardio-onc surveillance long-term home

Escalation triggers (move to higher acuity):
- Recurrent ACS → cardio-onc + cath via shared decision
- Late-onset cardiomyopathy → advanced HF eval
- Late-onset valvulopathy from radiation → cardiothoracic surgery consult
- Mental health deterioration → urgent psychiatry
- Cancer recurrence → re-engage cardio-onc framework

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Active tumor bleeding (GI/GU/intracranial/pulmonary cavity) precluding standard DAPT in cancer NSTEMI patient
- [LIFE_THREATENING] ICI myocarditis with new severe LV dysfunction OR new conduction abnormality (AV block, BBB) in patient on ICI within last 30–60 d
- [SEVERE] Platelets <50K in cancer NSTEMI patient — precludes most antithrombotics; requires shared decision re: ASA continuation, P2Y12 hold, parenteral AC hold, and cath strategy modification

Citations

- ESC 2022 Cardio-Oncology Guideline (PMID 36017575) + 2025 ACC/AHA ACS Guideline + ACC/AHA 2022 HF + ASCO 2018 ICI cardiotoxicity + MASTER DAPT [PMID:36017575](https://pubmed.ncbi.nlm.nih.gov/36017575/)
- Cited evidence (PMID 34516952) [PMID:34516952](https://pubmed.ncbi.nlm.nih.gov/34516952/)
- Cited evidence (PMID 31475798) [PMID:31475798](https://pubmed.ncbi.nlm.nih.gov/31475798/)
- Cited evidence (PMID 30013321) [PMID:30013321](https://pubmed.ncbi.nlm.nih.gov/30013321/)
- Cited evidence (PMID 31504080) [PMID:31504080](https://pubmed.ncbi.nlm.nih.gov/31504080/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ESC 2022 Cardio-Oncology Guideline (PMID 36017575) + 2025 ACC/AHA ACS Guideline + ACC/AHA 2022 HF + ASCO 2018 ICI cardiotoxicity + MASTER DAPT — PMID:36017575
  • Cited evidence (PMID 34516952) — PMID:34516952
  • Cited evidence (PMID 31475798) — PMID:31475798
  • Cited evidence (PMID 30013321) — PMID:30013321
  • Cited evidence (PMID 31504080) — PMID:31504080