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cardio.nstemi.high-risk.v1PRODUCTION
cardio.nstemi.high-risk.v1

High-risk NSTE-ACS (cath ≤24 h)

cardiologyacuteadult
Hard-required inputs
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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 high-risk NSTE-ACS stratum — GRACE >140 OR dynamic ECG OR hemodynamic/electrical instability OR refractory angina; route to parent cardio.nstemi.core.v1 for the universal regimen and add ≤24-h cath timing per ACC/AHA 2025 Class I + TIMACS PMID 19625657

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Advance rule
Set
Advance when

High-risk stratum confirmed; very-high-risk (≤2 h) excluded

Patient inputs (11)

EF, RWMA, mechanical complication screen in high-risk before cath

GRACE/TIMI age component; influences cath timing in elderly per After Eighty / SENIOR-RITA frailty subanalyses

Enoxaparin/UFH weight-based dosing; prasugrel weight ≥60 kg per TRITON-TIMI 38

Tachycardia component of GRACE; affects β-blocker initiation timing

Prasugrel CONTRAINDICATED if prior stroke/TIA; HAS-BLED gates triple-therapy duration

Dynamic rise/fall over 1 h confirms NSTEMI within high-risk stratum (ESC 2023 0/1-h algorithm)

GRACE creatinine component; contrast nephropathy planning before ≤24-h cath; KDIGO 2026

Baseline Hgb/platelets before triple antiplatelet+heparin upfront load

High-intensity statin on day 0 per ACC/AHA 2025; baseline LDL for 4-8 wk recheck

Serial ECG q15 min × first hour to detect dynamic changes / STEMI evolution

SBP <90 = SCAI B-C shock screen → very-high-risk pathway (≤2 h cath); also GRACE component

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningrefractory_angina_on_max_med
    Refractory angina despite max medical therapy — escalates to very-high-risk (≤2 h cath) per ACC/AHA 2025 Class I
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemodynamic_or_electrical_instability
    SBP <90 with hypoperfusion OR sustained VT/VF in high-risk NSTE-ACS — escalate to ≤2 h cath + MCS standby
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_in_high_risk_nsteacs
    New harsh murmur, pulmonary edema, or papillary rupture / VSD / free-wall rupture during high-risk NSTE-ACS
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregrace_above_140_confirmed
    GRACE >140 in NSTE-ACS context — high-risk stratum requiring cath ≤24 h per ACC/AHA 2025 Class I
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredynamic_ecg_changes_in_nsteacs
    New dynamic ST depression ≥0.5 mm or transient ST elevation or deep T-wave inversion during NSTE-ACS workup
    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

High-risk NSTE-ACS upfront triple antithrombotic load (ASA + P2Y12 + UFH/enoxaparin) — ACC/AHA 2025 Class I; ≤24 h cath
axis: high_risk_nsteacs_upfront_load
Selected axis "High-risk NSTE-ACS upfront triple antithrombotic load (ASA + P2Y12 + UFH/enoxaparin) — ACC/AHA 2025 Class I; ≤24 h cath" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg load → 81 mg • PO chewed • load once → 81 mg daily lifelong
    triggers: high_risk_nsteacs_no_dissection
    Universal — ACC/AHA 2025 Class I; ISIS-2 23% mortality reduction
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo standard DAPT
    triggers: high_risk_nsteacs_pci_planned
    PLATO PMID 19717846 + ISAR-REACT 5 PMID 31475799 — preferred upstream of anatomy in high-risk; ACC/AHA 2025 Class I
    rxcui 1116632
  • clopidogrel
    second line
    P2Y12_inhibitor
    600 mg load → 75 mg • PO • daily × 12 mo
    triggers: ticagrelor_contraindicated, on_oac_concomitant
    Alternative for HBR or on chronic OAC (AUGUSTUS / ENTRUST-AF PCI); ACC/AHA 2025 Class IIa
    rxcui 32968
  • 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_24h_planned
    ACC/AHA 2025 Class I default for invasive ≤24 h; reversible; renal-friendly
    rxcui 5224
  • enoxaparin
    first line
    LMWH
    1 mg/kg SC q12h (1 mg/kg q24h if CrCl 15-30) • SC • q12h until 24 h pre-cath then switch to UFH
    triggers: no_imminent_pci_within_8h, CrCl_ge_30
    ESSENCE PMID 11519503; switch to UFH at PCI per ACC/AHA 2025
    rxcui 67108
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • once daily
    triggers: high_risk_nsteacs_confirmed
    PROVE-IT PMID 15007110 — start day 0 high-intensity per ACC/AHA 2025 Class I
    rxcui 83367

outpatient playbook — drug actions (3)

  1. 1. continue DAPT
    aspirin 81 + ticagrelor 90 BID • PO • daily/BID
    trigger: Post-cath maintenance
    PARIS adherence-vs-stent-thrombosis; PLATO PMID 19717846
  2. 2. first up-titration of ACEi
    lisinopril 5 → 10 → 20 → 40 mg • PO • daily
    trigger: SBP >100 + K <5.0 + eGFR stable
    GISSI-3 mortality benefit at target dose
  3. 3. first up-titration of BB
    metoprolol succ 25 → 50 → 100 mg • PO • daily
    trigger: HR >55 + euvolemia + SBP >100
    CAPRICORN PMID 11356436

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: GRACE >140 in NSTE-ACS context — early-invasive Class I per ACC/AHA 2025; Dynamic ST depression ≥0.5 mm or transient ST elevation or deep T-wave inversion (high-risk feature, ACC/AHA 2025); Refractory angina despite max medical therapy (Class I emergent → ≤2 h consideration).

Objective

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

Assessment

**High-risk NSTE-ACS (cath ≤24 h)** (cardio.nstemi.high-risk.v1).
Phenotype framing: High-risk NSTE-ACS vs evolving STEMI vs type-2 MI vs Takotsubo vs myocarditis vs dissection per 4th UDMI 2018
Scope: Confirm high-risk NSTE-ACS stratum — GRACE >140 OR dynamic ECG OR hemodynamic/electrical instability OR refractory angina; route to parent cardio.nstemi.core.v1 for the universal regimen and add ≤24-h cath timing per ACC/AHA 2025 Class I + TIMACS PMID 19625657

No severity triggers fired against current inputs.

Plan

Regimen axis: **High-risk NSTE-ACS upfront triple antithrombotic load (ASA + P2Y12 + UFH/enoxaparin) — ACC/AHA 2025 Class I; ≤24 h cath**.
1. aspirin 162-325 mg load → 81 mg PO chewed load once → 81 mg daily lifelong (antiplatelet_cox1, first line) — Universal — ACC/AHA 2025 Class I; ISIS-2 23% mortality reduction
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo standard DAPT (P2Y12_inhibitor, first line) — PLATO PMID 19717846 + ISAR-REACT 5 PMID 31475799 — preferred upstream of anatomy in high-risk; ACC/AHA 2025 Class I
3. clopidogrel 600 mg load → 75 mg PO daily × 12 mo (P2Y12_inhibitor, second line) — Alternative for HBR or on chronic OAC (AUGUSTUS / ENTRUST-AF PCI); ACC/AHA 2025 Class IIa
4. unfractionated_heparin 60 U/kg bolus (max 4000) → 12 U/kg/h infusion IV continuous, aPTT 1.5-2× control (parenteral_anticoagulant, first line) — ACC/AHA 2025 Class I default for invasive ≤24 h; reversible; renal-friendly
5. enoxaparin 1 mg/kg SC q12h (1 mg/kg q24h if CrCl 15-30) SC q12h until 24 h pre-cath then switch to UFH (LMWH, first line) — ESSENCE PMID 11519503; switch to UFH at PCI per ACC/AHA 2025
6. atorvastatin 80 mg PO once daily (statin_high_intensity, first line) — PROVE-IT PMID 15007110 — start day 0 high-intensity per ACC/AHA 2025 Class I

Setting playbook (outpatient) — 1-week post-cath anchor visit — confirm DAPT adherence, complete unfinished GDMT, set chronic-CAD trajectory before formal handoff to chronic CAD engine
7. continue DAPT aspirin 81 + ticagrelor 90 BID PO daily/BID — Post-cath maintenance (PARIS adherence-vs-stent-thrombosis; PLATO PMID 19717846)
8. first up-titration of ACEi lisinopril 5 → 10 → 20 → 40 mg PO daily — SBP >100 + K <5.0 + eGFR stable (GISSI-3 mortality benefit at target dose)
9. first up-titration of BB metoprolol succ 25 → 50 → 100 mg PO daily — HR >55 + euvolemia + SBP >100 (CAPRICORN PMID 11356436)

Non-pharmacologic actions:
- Reinforce daily BP + symptom log
- Cardiac rehab kick-off if not started — 26% all-cause mortality reduction
- Smoking cessation reinforcement
- Mediterranean / DASH diet counseling

AVOID / contraindication checks:
- Antithrombotic block if active bleeding (ACC/AHA 2025 Class III)
- Prasugrel block if prior stroke TIA (TRITON TIMI 38)
- Ticagrelor block if bradyarrhythmia (PLATO)
- Enoxaparin renal dose adjust (ACC/AHA 2025; q24h if CrCl 15 30)

Monitoring

Regimen monitoring:
- Hgb q12h first 24 h on triple antithrombotic (BARC 2011)
- Platelets baseline then q3d (HIT screening per ACC/AHA 2025)
- Creatinine baseline then q24h on AC + post-contrast (KDIGO 2026)
- aPTT or anti-Xa per UFH protocol (ACC/AHA 2025 Class I)

Setting (outpatient) monitoring:
- BMP at week 4
- Lipid panel at week 4-8 — target LDL <70 (or <55 very-high-risk); add ezetimibe if above per IMPROVE-IT
- Bleeding signs check at every visit through 12 mo of DAPT

Follow-up plan: Cardiac rehab Class I, full 5-pillar GDMT, lipid recheck 4-8 wks per IMPROVE-IT, DAPT plan 12 mo standard or de-escalation per TWILIGHT/MASTER DAPT if HBR
- Close-out criterion: Discharge bundle + cardiac rehab booked

Monitoring phase: Continuous ECG/SpO2, repeat hsTn to peak, BMP/CBC q6-12 h on AC, bleeding signs each shift per BARC 2011

Disposition

Current setting: outpatient — 1-week post-cath anchor visit — confirm DAPT adherence, complete unfinished GDMT, set chronic-CAD trajectory before formal handoff to chronic CAD engine

Disposition criteria:
- Formal handoff to chronic CAD engine when 5-pillar GDMT at max-tolerated AND DAPT plan finalised AND lipid target met

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED
- BARC 2+ bleed → reassess DAPT — TWILIGHT PMID 31475798 or MASTER DAPT PMID 34516952 if HAS-BLED ≥3
- NYHA worsening to III+ → expedite cardiology re-eval + echo

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Refractory angina despite max medical therapy — escalates to very-high-risk (≤2 h cath) per ACC/AHA 2025 Class I
- [LIFE_THREATENING] SBP <90 with hypoperfusion OR sustained VT/VF in high-risk NSTE-ACS — escalate to ≤2 h cath + MCS standby
- [LIFE_THREATENING] New harsh murmur, pulmonary edema, or papillary rupture / VSD / free-wall rupture during high-risk NSTE-ACS

Citations

- 2025 ACC/AHA Guideline for ACS (Rao); ESC 2023 NSTE-ACS Guideline (Byrne, PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 19625657) [PMID:19625657](https://pubmed.ncbi.nlm.nih.gov/19625657/)
- Cited evidence (PMID 30156145) [PMID:30156145](https://pubmed.ncbi.nlm.nih.gov/30156145/)
- Cited evidence (PMID 19717846) [PMID:19717846](https://pubmed.ncbi.nlm.nih.gov/19717846/)
- Cited evidence (PMID 31475799) [PMID:31475799](https://pubmed.ncbi.nlm.nih.gov/31475799/)

Last reconciled with current guidelines: 2026-05-14.
References