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cardio.nstemi.intermediate-risk.v1PRODUCTION
cardio.nstemi.intermediate-risk.v1

Intermediate-risk NSTE-ACS (cath 25-72 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 intermediate-risk NSTE-ACS — GRACE 109-140 OR rising hsTn without dynamic ECG OR DM/CKD without high-risk features. Route through parent cardio.nstemi.core.v1 for universal regimen, schedule cath 25-72 h per ACC/AHA 2025 Class IIa + ESC 2023

Inputs
2
Actions
0
Advance rule
Set
Advance when

Intermediate stratum confirmed; high-risk features formally excluded

Patient inputs (11)

GRACE/TIMI age component; gates frailty + cath timing tradeoffs

Enoxaparin / UFH weight-based dosing

Hypotension would re-classify to high-risk; baseline for BB titration

GRACE component; titration of BB after invasive plan

0/1-h or 0/3-h ESC 2023 algorithm — confirms NSTEMI but rule out dynamic rise that would re-classify

Contrast nephropathy planning before 25-72 h cath; KDIGO 2026

Baseline Hgb/platelets before AC

High-intensity statin per ACC/AHA 2025

Newly diagnosed DM common in intermediate stratum; SGLT2i candidacy

Re-screen for dynamic changes that would re-classify to high-risk

EF + RWMA — EF<40 + intermediate features still warrants 25-72 h cath

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningreclassification_to_very_high_risk
    New SBP <90 + hypoperfusion OR sustained VT/VF during intermediate-risk admission
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverereclassification_to_high_risk
    New dynamic ECG OR refractory angina OR hemodynamic/electrical instability appears during intermediate-risk admission
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebleeding_on_intermediate_dapt
    Major bleeding (BARC 3+) on standard DAPT + AC during intermediate-risk admission
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategrace_109_to_140_confirmed
    GRACE 109-140 in NSTE-ACS — intermediate stratum, cath 25-72 h per ACC/AHA 2025 Class IIa
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterising_hstn_without_dynamic_ecg
    hsTn rise/fall over 1-3 h without dynamic ECG — confirms NSTEMI but does not re-classify to high-risk
    Trigger could not be auto-evaluated — needs clinician judgement.

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Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Intermediate-risk NSTE-ACS standard antithrombotic load (ASA + P2Y12 + LMWH preferred) — ACC/AHA 2025 + ESC 2023; 25-72 h cath
axis: intermediate_risk_nsteacs_standard_load
Selected axis "Intermediate-risk NSTE-ACS standard antithrombotic load (ASA + P2Y12 + LMWH preferred) — ACC/AHA 2025 + ESC 2023; 25-72 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: intermediate_risk_nsteacs_no_dissection
    Universal — ACC/AHA 2025 Class I
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo standard
    triggers: intermediate_risk_nsteacs_no_oac
    PLATO PMID 19717846 + ISAR-REACT 5 PMID 31475799 — preferred over clopidogrel
    rxcui 1116632
  • clopidogrel
    second line
    P2Y12_inhibitor
    600 mg load → 75 mg • PO • daily × 12 mo
    triggers: ticagrelor_contraindicated, on_oac, high_bleed_risk
    Alternative for HBR, on chronic OAC, or ticagrelor intolerant; ACC/AHA 2025 Class IIa
    rxcui 32968
  • 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 UFH
    triggers: intermediate_strategy_cath_in_25_to_72h, CrCl_ge_30
    ESSENCE PMID 11519503 — preferred for non-imminent cath in intermediate stratum; switch to UFH at PCI per ACC/AHA 2025
    rxcui 67108
  • unfractionated_heparin
    second line
    parenteral_anticoagulant
    60 U/kg bolus (max 4000) → 12 U/kg/h infusion • IV • continuous, aPTT 1.5-2× control
    triggers: CrCl_lt_30, cath_imminent
    Reversible, renal-friendly; preferred at PCI or in advanced CKD
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • once daily
    triggers: intermediate_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
    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
  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 109-140 in NSTE-ACS context — intermediate stratum, cath 25-72 h per ACC/AHA 2025 IIa; Rising hsTn without dynamic ECG changes — intermediate-risk feature; Diabetes or CKD presenting with NSTE-ACS lacking high-risk features.

Objective

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

Assessment

**Intermediate-risk NSTE-ACS (cath 25-72 h)** (cardio.nstemi.intermediate-risk.v1).
Phenotype framing: Intermediate-risk NSTE-ACS vs type-2 MI vs Takotsubo vs myocarditis per 4th UDMI 2018
Scope: Confirm intermediate-risk NSTE-ACS — GRACE 109-140 OR rising hsTn without dynamic ECG OR DM/CKD without high-risk features. Route through parent cardio.nstemi.core.v1 for universal regimen, schedule cath 25-72 h per ACC/AHA 2025 Class IIa + ESC 2023

No severity triggers fired against current inputs.

Plan

Regimen axis: **Intermediate-risk NSTE-ACS standard antithrombotic load (ASA + P2Y12 + LMWH preferred) — ACC/AHA 2025 + ESC 2023; 25-72 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
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo standard (P2Y12_inhibitor, first line) — PLATO PMID 19717846 + ISAR-REACT 5 PMID 31475799 — preferred over clopidogrel
3. clopidogrel 600 mg load → 75 mg PO daily × 12 mo (P2Y12_inhibitor, second line) — Alternative for HBR, on chronic OAC, or ticagrelor intolerant; ACC/AHA 2025 Class IIa
4. enoxaparin 1 mg/kg SC q12h (1 mg/kg q24h if CrCl 15-30) SC q12h until ~24 h pre-cath then UFH (LMWH, first line) — ESSENCE PMID 11519503 — preferred for non-imminent cath in intermediate stratum; switch to UFH at PCI per ACC/AHA 2025
5. unfractionated_heparin 60 U/kg bolus (max 4000) → 12 U/kg/h infusion IV continuous, aPTT 1.5-2× control (parenteral_anticoagulant, second line) — Reversible, renal-friendly; preferred at PCI or in advanced CKD
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
7. continue DAPT aspirin 81 + ticagrelor 90 BID PO daily/BID — Post-cath maintenance (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)
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
- 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)
- Enoxaparin renal dose adjust (ACC/AHA 2025; q24h if CrCl 15 30)
- Fondaparinux no mono AC during PCI (OASIS 5)

Monitoring

Regimen monitoring:
- Hgb q12h first 24 h on AC + DAPT (BARC 2011)
- Platelets baseline then q3d (HIT screening)
- Creatinine baseline then q24h on AC + post-contrast
- aPTT or anti-Xa per protocol

Setting (outpatient) monitoring:
- BMP at week 4
- Lipid panel at week 4-8 — target LDL <70 (or <55 very-high-risk)
- 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, DAPT 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 q12 h on AC, bleeding signs each shift; re-trigger high-risk pathway if dynamic ECG develops

Disposition

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

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

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED
- BARC 2+ bleed → reassess DAPT
- NYHA worsening to III+ → cardiology re-eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New SBP <90 + hypoperfusion OR sustained VT/VF during intermediate-risk admission
- [SEVERE] New dynamic ECG OR refractory angina OR hemodynamic/electrical instability appears during intermediate-risk admission
- [SEVERE] Major bleeding (BARC 3+) on standard DAPT + AC during intermediate-risk admission

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 19717846) [PMID:19717846](https://pubmed.ncbi.nlm.nih.gov/19717846/)
- Cited evidence (PMID 31475799) [PMID:31475799](https://pubmed.ncbi.nlm.nih.gov/31475799/)
- Cited evidence (PMID 23414246) [PMID:23414246](https://pubmed.ncbi.nlm.nih.gov/23414246/)

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