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cardio.nstemi.core.v1PRODUCTION
cardio.nstemi.core.v1

NSTEMI / NSTE-ACS (UA + NSTEMI)

cardiologyacuteadult
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm NSTE-ACS (UA vs NSTEMI) vs STEMI vs type-2 MI vs dissection vs PE vs myo/pericarditis vs non-cardiac (ACC/AHA 2021 Chest Pain evaluation algorithm)

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2
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Advance rule
Set
Advance when

Diagnosis narrowed and STEMI excluded

Patient inputs (17)

Risk stratification + drug selection (prasugrel ≤75 yr per TRITON-TIMI 38, Wiviott NEJM 2007); GRACE/TIMI age components

Prasugrel weight ≥60 kg per TRITON-TIMI 38 (Wiviott NEJM 2007); enoxaparin renal dosing per ACC/AHA 2025

Hypotension = high-risk per GRACE score; affects β-blocker / nitrate use (ACC/AHA 2025 ACS)

Tachycardia / bradycardia limit β-blocker; AF detection (ACC/AHA 2025 ACS, Class I)

Recurrent ACS shifts urgency; stent thrombosis differential (ACC/AHA 2025 ACS)

Prasugrel contraindicated if prior stroke / TIA (TRITON-TIMI 38, Wiviott NEJM 2007); risk-adjust DAPT duration per ACC/AHA 2025

Existing AC / antiplatelet / statin / BB; OAC for AF affects triple-therapy strategy (ACC/AHA 2025 ACS)

0/1-h or 0/3-h ESC 2023 algorithm; rise/fall confirms NSTEMI (ESC 2023 §3.3)

Contrast nephropathy risk; enoxaparin / DOAC dose adjustment; PCI risk score (ACC/AHA 2025)

Baseline Hgb / platelets before AC; transfusion threshold (ACC/AHA 2025 ACS, Class I)

PT/PTT/INR baseline before parenteral AC (ACC/AHA 2025 ACS)

Statin titration target LDL <70 / <55 in very-high-risk (ESC 2023 §5.5; ACC/AHA 2025)

Newly diagnosed DM common; SGLT2i candidacy (ADA 2026; ACC/AHA 2025)

Dynamic changes = high-risk; rule out STEMI (ACC/AHA 2025, Class I; ESC 2023 §3.2)

Pulmonary edema, widened mediastinum (dissection rule-out), pneumothorax (ACC/AHA 2021 Chest Pain)

Oxygen only if SpO2 <90% (AVOID trial, Stub Circulation 2015); ACC/AHA 2025 Class III-harm for routine O2

EF, RWMA, mechanical complications, pericardial effusion (ACC/AHA 2025, Class I for hemodynamic instability)

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningcardiogenic_shock
    SBP <90 with end-organ hypoperfusion or lactate >2 in NSTE-ACS per ACC/AHA 2025
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication
    New murmur, pulmonary edema, papillary muscle rupture, VSD, free-wall rupture per ACC/AHA 2025
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningevolution_to_stemi
    New persistent ST elevation during admission per ACC/AHA 2025 STEMI criteria
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregrace_gt_140_or_refractory_ischemia
    GRACE >140 or refractory ischemia or hemodynamic / electrical instability per ACC/AHA 2025
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_risk_invasive_24h
    GRACE 109–140, recurrent angina with dynamic ECG, EF<40, post-PCI/CABG, recent MI per ACC/AHA 2025
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebleeding_on_dapt
    Major bleeding (BARC 3+) on DAPT or triple therapy per BARC criteria 2011
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_with_contrast_planned
    eGFR <60 with planned contrast for cath per KDIGO 2026 AKI draft
    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

Acute antithrombotic regimen for NSTE-ACS — phenotype-stratified per ACC/AHA 2025 + ESC 2023
axis: nsteacs_acute_antithromboticstep 1 - Step 1 — Very-high-risk (cath ≤2 h)
Selected step "Step 1 — Very-high-risk (cath ≤2 h)" — Refractory ischemia despite GTN, hemodynamic instability (SBP <90 + hypoperfusion), electrical instability (sustained VT/VF), mechanical complication (acute MR / VSD / free-wall rupture), intractable angina at rest (ACC/AHA 2025 Class I)
  • aspirin
    first line
    antiplatelet
    162–325 mg load → 81 mg • PO chewed • load once → 81 mg daily lifelong
    triggers: NSTE_ACS_confirmed_no_dissection
    Universal — ACC/AHA 2025 Class I; ISIS-2 (Lancet 1988) 23% mortality reduction
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID for 12 mo
    triggers: very_high_risk_NSTE_ACS
    PLATO HR 0.84 vs clopidogrel (PMID 19717846); preferred upstream of anatomy per ISAR-REACT 5 design (PMID 31475799); ACC/AHA 2025 Class I
    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
    triggers: cath_le_2h_planned
    Default for emergent invasive per ACC/AHA 2025 Class I; reversible
    rxcui 5224

outpatient playbook — drug actions (5)

  1. 1. continue DAPT (verify regimen)
    aspirin 81 + ticagrelor 90 BID OR clopidogrel 75 daily • PO • daily/BID
    trigger: Post-cath maintenance
    Adherence is single largest determinant of stent thrombosis (PARIS registry); ACC/AHA 2025 Class I; PLATO PMID 19717846
  2. 2. first up-titration of ACEi (if started low)
    lisinopril 5 → 10 → 20 → 40 mg daily • PO • daily
    trigger: SBP >100 + K <5.0 + eGFR stable + tolerated 1 week
    GISSI-3 mortality benefit at target dose; ACC/AHA 2025 Class I if EF<40 / HTN / DM / CKD
  3. 3. first up-titration of BB
    metoprolol succ 25 → 50 → 100 mg daily, OR carvedilol 3.125 → 6.25 BID • PO • daily/BID
    trigger: HR >55 + euvolemia + SBP >100
    CAPRICORN PMID 11356434 — HR 0.77 mortality post-MI EF<40 at target dose
  4. 4. add MRA if EF<40 + post-MI + HF or DM and not yet started
    spironolactone 12.5 → 25 mg daily OR eplerenone 25 → 50 mg daily • PO • daily
    trigger: K <5.0 + eGFR ≥30 + EF<40 + HF or DM
    EPHESUS PMID 12668699 — all-cause death HR 0.85 post-MI EF<40
  5. 5. continue/add SGLT2i if DM2 + ASCVD or HFrEF
    dapagliflozin 10 mg or empagliflozin 10 mg daily • PO • daily
    trigger: DM2 + ASCVD OR HFrEF post-MI; eGFR >20
    EMPA-REG (PMID 26378978); DAPA-MI PMID 38320489; ACC/AHA 2025 Class IIa

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Ischemic-pattern chest pain or anginal equivalent (ACC/AHA 2025 ACS, Class I); High-sensitivity troponin elevation in appropriate clinical context (ESC 2023 0/1-h algorithm); Dynamic ECG changes (ST depression ≥0.5 mm or T-wave inversion) per ACC/AHA 2021 Chest Pain §4.3.

Objective

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

Assessment

**NSTEMI / NSTE-ACS (UA + NSTEMI)** (cardio.nstemi.core.v1).
Phenotype framing: STEMI / NSTEMI / UA / type-2 MI / Takotsubo / myocarditis / dissection / PE / pericarditis / GERD / MSK — Fourth Universal Definition of MI 2018
Scope: Confirm NSTE-ACS (UA vs NSTEMI) vs STEMI vs type-2 MI vs dissection vs PE vs myo/pericarditis vs non-cardiac (ACC/AHA 2021 Chest Pain evaluation algorithm)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute antithrombotic regimen for NSTE-ACS — phenotype-stratified per ACC/AHA 2025 + ESC 2023** — step "Step 1 — Very-high-risk (cath ≤2 h)".
1. aspirin 162–325 mg load → 81 mg PO chewed load once → 81 mg daily lifelong (antiplatelet, first line) — Universal — ACC/AHA 2025 Class I; ISIS-2 (Lancet 1988) 23% mortality reduction
2. ticagrelor 180 mg load → 90 mg BID PO BID for 12 mo (P2Y12_inhibitor, first line) — PLATO HR 0.84 vs clopidogrel (PMID 19717846); preferred upstream of anatomy per ISAR-REACT 5 design (PMID 31475799); ACC/AHA 2025 Class I
3. unfractionated_heparin 60 U/kg bolus (max 4000) → 12 U/kg/h infusion IV continuous; aPTT 1.5–2× control (parenteral_anticoagulant, first line) — Default for emergent invasive per ACC/AHA 2025 Class I; reversible

Setting playbook (outpatient) — 1-week post-cath anchor visit — confirm DAPT adherence, complete unfinished GDMT initiation, lipid recheck booking, set the chronic-CAD secondary-prevention trajectory before formal handoff to the chronic CAD engine. Bridges from acute-NSTE-ACS to chronic CAD secondary prevention per ACC/AHA 2025 Class I.
4. continue DAPT (verify regimen) aspirin 81 + ticagrelor 90 BID OR clopidogrel 75 daily PO daily/BID — Post-cath maintenance (Adherence is single largest determinant of stent thrombosis (PARIS registry); ACC/AHA 2025 Class I; PLATO PMID 19717846)
5. first up-titration of ACEi (if started low) lisinopril 5 → 10 → 20 → 40 mg daily PO daily — SBP >100 + K <5.0 + eGFR stable + tolerated 1 week (GISSI-3 mortality benefit at target dose; ACC/AHA 2025 Class I if EF<40 / HTN / DM / CKD)
6. first up-titration of BB metoprolol succ 25 → 50 → 100 mg daily, OR carvedilol 3.125 → 6.25 BID PO daily/BID — HR >55 + euvolemia + SBP >100 (CAPRICORN PMID 11356434 — HR 0.77 mortality post-MI EF<40 at target dose)
7. add MRA if EF<40 + post-MI + HF or DM and not yet started spironolactone 12.5 → 25 mg daily OR eplerenone 25 → 50 mg daily PO daily — K <5.0 + eGFR ≥30 + EF<40 + HF or DM (EPHESUS PMID 12668699 — all-cause death HR 0.85 post-MI EF<40)
8. continue/add SGLT2i if DM2 + ASCVD or HFrEF dapagliflozin 10 mg or empagliflozin 10 mg daily PO daily — DM2 + ASCVD OR HFrEF post-MI; eGFR >20 (EMPA-REG (PMID 26378978); DAPA-MI PMID 38320489; ACC/AHA 2025 Class IIa)

Non-pharmacologic actions:
- Reinforce daily BP + symptom log (ACC/AHA 2025)
- Cardiac rehab kick-off if not started — meta-analysis 26% all-cause mortality reduction (ACC/AHA 2025 Class I)
- Confirm next visit booked at week 4–6 for lipid recheck + further GDMT titration
- Smoking cessation reinforcement — pharmacotherapy + behavioural support (ACC/AHA 2025 Class I)
- Mediterranean / DASH diet counseling (ACC/AHA 2025 Class IIa)

AVOID / contraindication checks:
- Antithrombotic block if active bleeding (ACC/AHA 2025 Class III)
- Prasugrel block if prior stroke TIA (TRITON TIMI 38, Wiviott NEJM 2007)
- Ticagrelor block if bradyarrhythmia (PLATO, Wallentin NEJM 2009 — dyspnea/bradycardia signal)
- Enoxaparin renal dose adjust (ACC/AHA 2025; reduce to q24h if CrCl 15–30)
- Fondaparinux no mono AC during PCI (OASIS 5, Yusuf NEJM 2006 — catheter thrombosis)

Monitoring

Regimen monitoring:
- Hgb q12h first 24 h per ACC/AHA 2025 ACS bleeding monitoring
- Platelets baseline then q3d (HIT screening per ACC/AHA 2025)
- Creatinine baseline then q24h on parenteral AC (ACC/AHA 2025)
- aPTT or anti-Xa per UFH protocol (ACC/AHA 2025, Class I)
- Bleeding signs assessment each shift (BARC criteria 2011)

Setting (outpatient) monitoring:
- BMP at next visit (week 4) — earlier if eGFR borderline or K trending up
- Lipid panel at week 4–8 — target LDL <70 (or <55 if very-high-risk per ESC 2023); add ezetimibe if above target per IMPROVE-IT PMID 26039521
- Bleeding signs check at every visit through 12 mo of DAPT
- A1c at 3 mo if newly diagnosed DM2 (ADA 2026)

Follow-up plan: Cardiac rehab (ACC/AHA 2025 Class I), GDMT optimisation, lipid recheck 4–8 wks, DAPT duration plan per PLATO / TWILIGHT, lifestyle, vaccinations
- Close-out criterion: Follow-up booked + plan written

Monitoring phase: Telemetry, serial troponin, renal function on AC, bleeding signs, ECG with each pain (ACC/AHA 2025 ACS, Class I)

Disposition

Current setting: outpatient — 1-week post-cath anchor visit — confirm DAPT adherence, complete unfinished GDMT initiation, lipid recheck booking, set the chronic-CAD secondary-prevention trajectory before formal handoff to the chronic CAD engine. Bridges from acute-NSTE-ACS to chronic CAD secondary prevention per ACC/AHA 2025 Class I.

Disposition criteria:
- Confirm continuation in transition setting (next visit week 4–6) — formal handoff to chronic CAD secondary-prevention engine occurs when all 5 GDMT pillars titrated to max-tolerated dose AND DAPT plan finalised AND lipid target met (LDL <70 or <55) AND cardiac rehab phase II completed

Escalation triggers (move to higher acuity):
- Recurrent chest pain or anginal equivalent → ED for serial hsTn + ECG (ACC/AHA 2025)
- BARC 2+ bleed → reassess DAPT — consider TWILIGHT PMID 31556978 (ASA d/c, ticagrelor mono) or MASTER DAPT PMID 34449185 (1-mo DAPT then SAPT) per HAS-BLED ≥3
- K >5.5 on MRA → hold MRA first, consider patiromer/SZC
- Cr rise >30% from discharge → reduce ACEi/ARB; reassess volume; route to ED if symptomatic AKI
- NYHA worsening to III+ → expedite cardiology re-evaluation + echo (ACC/AHA 2025)
- Symptomatic hypotension after BB up-titration → hold next dose, recheck in 1 week

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 with end-organ hypoperfusion or lactate >2 in NSTE-ACS per ACC/AHA 2025
- [LIFE_THREATENING] New murmur, pulmonary edema, papillary muscle rupture, VSD, free-wall rupture per ACC/AHA 2025
- [LIFE_THREATENING] New persistent ST elevation during admission per ACC/AHA 2025 STEMI criteria

Citations

- 2025 ACC/AHA Guideline for ACS (Rao); ESC 2023 NSTE-ACS Guideline (Byrne, PMID 37622654); ACC/AHA 2021 Chest Pain Guideline (Gulati, PMID 34709879) [PMID:19717846](https://pubmed.ncbi.nlm.nih.gov/19717846/)
- Cited evidence (PMID 17982182) [PMID:17982182](https://pubmed.ncbi.nlm.nih.gov/17982182/)
- Cited evidence (PMID 15007110) [PMID:15007110](https://pubmed.ncbi.nlm.nih.gov/15007110/)
- Cited evidence (PMID 26039521) [PMID:26039521](https://pubmed.ncbi.nlm.nih.gov/26039521/)
- Cited evidence (PMID 28304224) [PMID:28304224](https://pubmed.ncbi.nlm.nih.gov/28304224/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2025 ACC/AHA Guideline for ACS (Rao); ESC 2023 NSTE-ACS Guideline (Byrne, PMID 37622654); ACC/AHA 2021 Chest Pain Guideline (Gulati, PMID 34709879) — PMID:19717846
  • Cited evidence (PMID 17982182) — PMID:17982182
  • Cited evidence (PMID 15007110) — PMID:15007110
  • Cited evidence (PMID 26039521) — PMID:26039521
  • Cited evidence (PMID 28304224) — PMID:28304224