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cardio.nstemi.post-cabg-perioperative.v1PRODUCTION
cardio.nstemi.post-cabg-perioperative.v1

NSTEMI peri-operative — within 30 days post-CABG (UDMI Type 5 NSTEMI variant)

cardiologyacuteadult
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12/12 authored

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

Current phase

Frame

Detailed

Confirm post-CABG NSTEMI per 4th UDMI Type 5 (Thygesen 2018 PMID 30153967): cTn >10× URL cTnT (or >35× URL cTnI) within 48 h of CABG, OR sustained rise/re-rise after expected post-pump fall, PLUS new Q waves / new LBBB / new occlusion / new RWMA, AND no STE (this engine is NSTEMI variant). Three drivers to discriminate: early graft thrombosis (focal RWMA + culprit), distal embolization / incomplete revasc (diffuse), or type-2 peri-op demand ischemia (anemia, hypotension, AF/RVR, sepsis)

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UDMI Type 5 NSTEMI confirmed + driver hypothesis framed

Patient inputs (11)

Post-CABG patients skew older; bleed + AKI risk modify cath + DAPT decisions

Peri-op anemia drives type-2 demand; TRICS-III restrictive Hgb 7.5 threshold in cardiac surgery (PMID 29214843) — but if MI suspected lower threshold for transfusion to >8-9

Post-CPB AKI common; gates contrast volume + DOAC dosing + cath risk-benefit per KDIGO 2026

AF with RVR is most common post-CABG arrhythmia (30-40% incidence) and a frequent type-2 trigger; rate control is primary therapy

Most patients on chronic ASA + clopidogrel post-CABG (POPULAR-CABG PMID 34016267); chest-tube output + sternotomy bleed risk gates UFH + P2Y12 escalation; coordinate with CT-surgery before loading

CABG date (days post-op critical), grafts placed (LIMA-LAD, SVG-OM, SVG-RCA, etc.), residual ungrafted disease per surgical report, intra-op events (long pump time, difficult anastomosis, on/off-pump) — drives culprit-vessel hypothesis + peri-op MI classification

UDMI Type 5 requires >10× URL cTnT (or >35× URL cTnI) AND additional criterion (Q wave, occlusion, RWMA); baseline post-pump trop expected elevated — pattern (sustained rise vs fall toward baseline) is diagnostic

Confirm absence of STE (this is NSTEMI variant); detect new Q waves, new LBBB, ST depression / T inversion patterns; routine post-CABG ECG changes (pericarditis pattern, BBB) confound

Compare to pre-op + immediate post-op echo for new RWMA — UDMI Type 5 imaging criterion; also pericardial effusion (post-CABG) + tamponade (sternotomy adhesion masks classic signs)

Hypotension as both trigger (type-2 demand) and red flag (graft thrombosis with shock); MAP <65 → vasopressor + cath consideration

Active chest tube bleeding + sternal dehiscence risk → contraindication to UFH escalation; CT-surgery clearance required before DAPT load in first 7 d

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningcardiogenic_shock_in_post_cabg_nstemi
    SBP <90 + lactate ≥2 + hypoperfusion in post-CABG NSTEMI patient — graft thrombosis with shock, vasoplegia overlap, or mechanical complication; lower MCS threshold given advanced CAD substrate
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_post_cabg_in_nstemi_window
    New murmur, pulmonary edema, RV failure in post-CABG NSTEMI — papillary muscle rupture, VSD, free-wall rupture, or graft anastomotic dehiscence
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregraft_thrombosis_confirmed_or_strongly_suspected
    New focal RWMA on echo + sustained trop rise + hemodynamic concern in post-CABG NSTEMI patient — early graft thrombosis (LIMA spasm or SVG occlusion) suspect
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereactive_chest_tube_bleed_or_sternal_dehiscence_with_nstemi
    Chest tube output >100 mL/h × 4 h or sternal dehiscence in post-CABG NSTEMI patient — UFH + DAPT escalation contraindicated; bleed-control bundle priority
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesevere_anemia_driving_type2_demand_in_post_cabg_nstemi
    Hgb <8 in post-CABG NSTEMI patient with rising trop and demand-supply mismatch features — type-2 demand component dominant
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_op_af_with_demand_ischemia_in_nstemi_window
    New POAF with RVR + rising trop in post-CABG NSTEMI patient — type-2 demand from rate-driven ischemia; rate or rhythm control primary therapy
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Post-CABG peri-operative NSTEMI phenotype — driver-stratified regimen with CT-surgery-coordinated anti-thrombotic escalation; specialises parent cardio.nstemi.core.v1 for the 30-day post-CABG window
axis: post_cabg_perioperative_nstemi_phenotype
Selected axis "Post-CABG peri-operative NSTEMI phenotype — driver-stratified regimen with CT-surgery-coordinated anti-thrombotic escalation; specialises parent cardio.nstemi.core.v1 for the 30-day post-CABG window" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    continue 81 mg daily (load 162-325 mg only if not previously on ASA) • PO • daily indefinitely
    triggers: post_cabg_nstemi_confirmed
    AHA 2025 ACS Class I + ACC/AHA 2021 Coronary Revasc (PMID 34882435) — lifelong post-CABG ASA; rarely needs new load since most post-CABG patients on chronic ASA
    rxcui 243670
  • clopidogrel
    first line
    P2Y12_inhibitor
    75 mg daily (continue if already on; load 300 mg only with CT-surg clearance if escalating from ASA-mono) • PO • daily × 12 mo per POPULAR-CABG PMID 34016267
    triggers: post_cabg_nstemi_confirmed, graft_thrombosis_suspected_or_confirmed
    POPULAR-CABG PMID 34016267 — clopidogrel preferred P2Y12 in post-CABG window given bleed profile; CT-surg clearance mandatory before reload in first 7 d
    rxcui 32968
  • ticagrelor
    second line
    P2Y12_inhibitor
    180 mg load → 90 mg BID (ONLY after CT-surg clearance + chest tubes <100 mL/h × 4 h + day ≥7 post-op) • PO • BID × 12 mo if escalation indicated
    triggers: confirmed_graft_thrombosis_with_pci_planned, recurrent_ischemia_despite_clopidogrel
    PLATO PMID 19717846 — net benefit in ACS but bleed risk amplified peri-op; reserved for confirmed graft thrombosis + CT-surg clearance
    rxcui 1116632
  • unfractionated_heparin
    first line
    parenteral_anticoagulant
    60 U/kg IV bolus + 12 U/kg/h infusion (HOLD if active chest tube bleed >100 mL/h or sternal dehiscence; CT-surg clearance mandatory) • IV • bolus + infusion at PCI; aPTT 50-70 or anti-Xa 0.3-0.7
    triggers: post_cabg_nstemi_pci_planned, ct_surg_cleared
    AHA 2025 Class I peri-PCI AC; UFH preferred over LMWH/fondaparinux in post-CABG window for reversibility (protamine) given bleed risk
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg daily • PO • daily lifelong
    triggers: post_cabg_nstemi_confirmed
    PROVE-IT PMID 15007110 — high-intensity statin lifelong; intensified post-CABG given graft attrition + advanced CAD substrate
    rxcui 83367
  • metoprolol_tartrate
    first line
    beta_blocker_cardioselective
    12.5-25 mg BID titrate (HOLD if SBP <100, HR <60, EF <30 + acute decompensation) • PO • BID
    triggers: post_cabg_nstemi_with_af_rvr, post_cabg_nstemi_post_event
    CAPRICORN + ACC/AHA 2025 Class I post-MI BB; rate control for POAF (incidence 30-40% post-CABG)
    rxcui 6918
  • norepinephrine
    rescue
    vasopressor
    0.05-0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: post_cabg_nstemi_with_vasoplegia_or_cs
    SOAP-II first-line vasopressor; vasoplegia common post-pump; restoring perfusion corrects type-2 demand component
    rxcui 7512
  • amiodarone
    add on
    antiarrhythmic_class_iii
    150 mg IV load over 10 min → 1 mg/min × 6 h → 0.5 mg/min • IV • load + infusion
    triggers: post_cabg_af_rvr_with_demand_ischemia, sustained_vt_post_cabg
    AHA 2024 AF rate/rhythm control; POAF + demand ischemia + EF reduced; first-line for sustained VT post-op
    rxcui 203114
  • sacubitril-valsartan
    add on
    arni
    24/26 mg BID titrate (start at ≥36 h post-ACEi, SBP ≥100) • PO • BID
    triggers: post_cabg_nstemi_with_ef_below_40_post_event
    PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF Class I — initiate ARNI if HFrEF persists post-MI in stable post-op patient
    rxcui 1656328
  • eptifibatide
    rescue
    gp_iib_iiia_inhibitor
    180 µg/kg IV bolus + 2 µg/kg/min infusion (renal-adjust if eGFR <50) • IV • bolus + infusion at PCI for SVG no-reflow / large thrombus burden
    triggers: svg_pci_no_reflow, large_thrombus_burden_at_pci
    EARLY ACS / TARGET — bailout GPIIb/IIIa for SVG-PCI no-reflow despite embolic protection; bleed risk amplified peri-op so reserved for true bailout
    rxcui 75635
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR 2-3 × 3 mo if LV thrombus on echo • PO • daily
    triggers: lv_thrombus_on_post_event_echo, post_op_af_with_high_cha2ds2vasc
    AHA 2022 Class IIa — 3-mo AC for LV thrombus; AUGUSTUS framework if AF + ACS overlap (DAPT triple-therapy short window)
    rxcui 11289

outpatient playbook — drug actions (3)

  1. 1. continue ASA + clopidogrel 12 mo (POPULAR-CABG default)
    rxcui 32968
    aspirin 81 + clopidogrel 75 • PO • daily
    trigger: Post-CABG NSTEMI
    POPULAR-CABG PMID 34016267 — 12 mo standard; PRECISE-DAPT ≥25 → consider 3-6 mo shortening
  2. 2. maintain GDMT
    rxcui 83367
    atorvastatin 40-80 + BB low + ACEi low + MRA per renal/K • PO • daily
    trigger: Post-MI maintenance
    ACC/AHA 2025 Class I
  3. 3. add PCSK9i if LDL >70 on max statin
    evolocumab 140 mg SC q2w • SC • q2w
    trigger: LDL >70 on max statin + post-CABG (very-high-risk)
    FOURIER PMID 28304224 — additive LDL + MACE benefit; appropriate post-CABG given graft attrition

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Troponin rise meeting UDMI Type 5 NSTEMI threshold (>10× URL cTnT / >35× URL cTnI within 48 h of CABG, OR sustained rise after expected post-pump fall) without ST elevation; Post-CABG troponin re-rise (after the expected initial post-pump fall toward baseline by 24-72 h) — graft thrombosis or distal embolization suspect; Recurrent ischemic chest pain (or angina-equivalent: dyspnea, diaphoresis, hypotension) within 30 days post-CABG without STE.

Objective

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

Assessment

**NSTEMI peri-operative — within 30 days post-CABG (UDMI Type 5 NSTEMI variant)** (cardio.nstemi.post-cabg-perioperative.v1).
Phenotype framing: UDMI Type 5 NSTEMI sub-classification: (1) early graft thrombosis (focal RWMA + culprit on cath), (2) distal embolization / incomplete revasc (diffuse, often non-territorial), (3) type-2 peri-op demand ischemia (clear extracardiac trigger + slow plateau); pericarditis post-pump can mimic; PE post-op also in differential
Scope: Confirm post-CABG NSTEMI per 4th UDMI Type 5 (Thygesen 2018 PMID 30153967): cTn >10× URL cTnT (or >35× URL cTnI) within 48 h of CABG, OR sustained rise/re-rise after expected post-pump fall, PLUS new Q waves / new LBBB / new occlusion / new RWMA, AND no STE (this engine is NSTEMI variant). Three drivers to discriminate: early graft thrombosis (focal RWMA + culprit), distal embolization / incomplete revasc (diffuse), or type-2 peri-op demand ischemia (anemia, hypotension, AF/RVR, sepsis)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Post-CABG peri-operative NSTEMI phenotype — driver-stratified regimen with CT-surgery-coordinated anti-thrombotic escalation; specialises parent cardio.nstemi.core.v1 for the 30-day post-CABG window**.
1. aspirin continue 81 mg daily (load 162-325 mg only if not previously on ASA) PO daily indefinitely (antiplatelet_cox1, first line) — AHA 2025 ACS Class I + ACC/AHA 2021 Coronary Revasc (PMID 34882435) — lifelong post-CABG ASA; rarely needs new load since most post-CABG patients on chronic ASA
2. clopidogrel 75 mg daily (continue if already on; load 300 mg only with CT-surg clearance if escalating from ASA-mono) PO daily × 12 mo per POPULAR-CABG PMID 34016267 (P2Y12_inhibitor, first line) — POPULAR-CABG PMID 34016267 — clopidogrel preferred P2Y12 in post-CABG window given bleed profile; CT-surg clearance mandatory before reload in first 7 d
3. ticagrelor 180 mg load → 90 mg BID (ONLY after CT-surg clearance + chest tubes <100 mL/h × 4 h + day ≥7 post-op) PO BID × 12 mo if escalation indicated (P2Y12_inhibitor, second line) — PLATO PMID 19717846 — net benefit in ACS but bleed risk amplified peri-op; reserved for confirmed graft thrombosis + CT-surg clearance
4. unfractionated_heparin 60 U/kg IV bolus + 12 U/kg/h infusion (HOLD if active chest tube bleed >100 mL/h or sternal dehiscence; CT-surg clearance mandatory) IV bolus + infusion at PCI; aPTT 50-70 or anti-Xa 0.3-0.7 (parenteral_anticoagulant, first line) — AHA 2025 Class I peri-PCI AC; UFH preferred over LMWH/fondaparinux in post-CABG window for reversibility (protamine) given bleed risk
5. atorvastatin 80 mg daily PO daily lifelong (statin_high_intensity, first line) — PROVE-IT PMID 15007110 — high-intensity statin lifelong; intensified post-CABG given graft attrition + advanced CAD substrate
6. metoprolol_tartrate 12.5-25 mg BID titrate (HOLD if SBP <100, HR <60, EF <30 + acute decompensation) PO BID (beta_blocker_cardioselective, first line) — CAPRICORN + ACC/AHA 2025 Class I post-MI BB; rate control for POAF (incidence 30-40% post-CABG)
7. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor, rescue) — SOAP-II first-line vasopressor; vasoplegia common post-pump; restoring perfusion corrects type-2 demand component
8. amiodarone 150 mg IV load over 10 min → 1 mg/min × 6 h → 0.5 mg/min IV load + infusion (antiarrhythmic_class_iii, add on) — AHA 2024 AF rate/rhythm control; POAF + demand ischemia + EF reduced; first-line for sustained VT post-op
9. sacubitril-valsartan 24/26 mg BID titrate (start at ≥36 h post-ACEi, SBP ≥100) PO BID (arni, add on) — PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF Class I — initiate ARNI if HFrEF persists post-MI in stable post-op patient
10. eptifibatide 180 µg/kg IV bolus + 2 µg/kg/min infusion (renal-adjust if eGFR <50) IV bolus + infusion at PCI for SVG no-reflow / large thrombus burden (gp_iib_iiia_inhibitor, rescue) — EARLY ACS / TARGET — bailout GPIIb/IIIa for SVG-PCI no-reflow despite embolic protection; bleed risk amplified peri-op so reserved for true bailout
11. warfarin 5 mg daily; INR 2-3 × 3 mo if LV thrombus on echo PO daily (vitamin_k_antagonist, comorbidity specific) — AHA 2022 Class IIa — 3-mo AC for LV thrombus; AUGUSTUS framework if AF + ACS overlap (DAPT triple-therapy short window)

Setting playbook (outpatient) — 3-12 mo follow-up — DAPT-duration decision per POPULAR-CABG (12 mo default; PRECISE-DAPT-driven shortening if HBR), long-term GDMT optimisation, cardiac rehab maintenance, intensified secondary prevention with PCSK9 if LDL >70
12. continue ASA + clopidogrel 12 mo (POPULAR-CABG default) aspirin 81 + clopidogrel 75 PO daily — Post-CABG NSTEMI (POPULAR-CABG PMID 34016267 — 12 mo standard; PRECISE-DAPT ≥25 → consider 3-6 mo shortening)
13. maintain GDMT atorvastatin 40-80 + BB low + ACEi low + MRA per renal/K PO daily — Post-MI maintenance (ACC/AHA 2025 Class I)
14. add PCSK9i if LDL >70 on max statin evolocumab 140 mg SC q2w SC q2w — LDL >70 on max statin + post-CABG (very-high-risk) (FOURIER PMID 28304224 — additive LDL + MACE benefit; appropriate post-CABG given graft attrition)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase
- Annual flu + COVID + pneumococcal vaccination per CDC
- Smoking cessation reinforcement at every visit
- Mediterranean / DASH diet counseling
- BP + symptom log review at every visit

AVOID / contraindication checks:
- NEVER_load_p2y12_or_anticoagulate_without_ct_surg_clearance_in_first_7d (chest tube + sternal bleed risk)
- Hold_uft_if_chest_tube_output_above_100ml_per_hour_x_4h (active surgical bleed)
- Ticagrelor_avoid_intracranial_hemorrhage_history (FDA label)
- Transfuse_to_above_8_or_9_in_post_cabg_with_active_mi (lower threshold than TRICS III restrictive 7.5 given ischemia)
- Contrast_minimisation_egfr_below_30 (KDIGO 2026; full graft + native angio is high contrast)
- No_routine_thrombolytic_post_cabg (ACC/AHA 2025; PCI strongly preferred + bleed amplification)
- Warfarin_avoid_active_bleeding (AHA 2022)
- NSAID_avoid_in_post_cabg_window (renal + bleed amplification)

Monitoring

Regimen monitoring:
- serial troponin q3-6h during initial workup then q12h to confirm correction
- serial ecg q15min x 1h if ongoing pain then daily
- echo at 5-7d for lv thrombus screen + lv function
- creatinine q24h x 72h for CIN-AKI surveillance (high contrast load if cath)
- hgb + plt q12h x 24h then q24h during anticoagulation
- chest tube output + sternal exam each shift
- continuous telemetry for POAF + arrhythmia surveillance
- lvef re-echo at 40-90d for icd eligibility (MADIT-II)
- lipid panel at 4-12 weeks for pcsk9 decision if ldl above 70

Setting (outpatient) monitoring:
- BMP every 3 mo on ACEi/MRA
- Lipid panel every 6-12 mo
- Bleeding signs check at every visit through DAPT duration
- Echo at 1 yr if EF<40 — ICD candidacy
- Hgb annually

Follow-up plan: Cardiology + CT-surgery joint follow-up at 1, 4, 12 wks; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab Class I per ACC/AHA 2025; intensified secondary prevention (high-intensity statin lifelong, BP <130/80, no smoking, GDMT if EF reduced); DAPT-duration plan per POPULAR-CABG (PMID 34016267)
- Close-out criterion: Long-term joint follow-up + cardiac rehab booked

Monitoring phase: Telemetry; serial trop to confirm trigger correction normalises trend; daily ECG + echo at 5-7 d for thrombus + LV function reassessment; chest tube + sternal exam each shift; renal trajectory (CIN-AKI surveillance); AF surveillance (POAF up to 30-40% incidence)

Disposition

Current setting: outpatient — 3-12 mo follow-up — DAPT-duration decision per POPULAR-CABG (12 mo default; PRECISE-DAPT-driven shortening if HBR), long-term GDMT optimisation, cardiac rehab maintenance, intensified secondary prevention with PCSK9 if LDL >70

Disposition criteria:
- Long-term continuation; cross-link to chronic CAD engine; geriatrics co-management if frail

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED + reassess invasive vs medical
- BARC 2+ bleed → de-escalate DAPT immediately
- NYHA worsening to III+ → expedite cardiology re-eval + echo
- Late graft failure on stress / CTA → re-cath consideration

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 + lactate ≥2 + hypoperfusion in post-CABG NSTEMI patient — graft thrombosis with shock, vasoplegia overlap, or mechanical complication; lower MCS threshold given advanced CAD substrate
- [LIFE_THREATENING] New murmur, pulmonary edema, RV failure in post-CABG NSTEMI — papillary muscle rupture, VSD, free-wall rupture, or graft anastomotic dehiscence
- [SEVERE] New focal RWMA on echo + sustained trop rise + hemodynamic concern in post-CABG NSTEMI patient — early graft thrombosis (LIMA spasm or SVG occlusion) suspect

Citations

- 4th Universal Definition of MI 2018 (Thygesen Circulation 2018, PMID 30153967) Type-5 criteria; 2025 ACC/AHA ACS Guideline (Rao); ACC/AHA 2021 Coronary Revascularization Guideline (Lawton, PMID 34882435); ESC 2023 NSTE-ACS (Byrne, PMID 37622670) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)
- Cited evidence (PMID 34882435) [PMID:34882435](https://pubmed.ncbi.nlm.nih.gov/34882435/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 35105183) [PMID:35105183](https://pubmed.ncbi.nlm.nih.gov/35105183/)
- Cited evidence (PMID 11815441) [PMID:11815441](https://pubmed.ncbi.nlm.nih.gov/11815441/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 4th Universal Definition of MI 2018 (Thygesen Circulation 2018, PMID 30153967) Type-5 criteria; 2025 ACC/AHA ACS Guideline (Rao); ACC/AHA 2021 Coronary Revascularization Guideline (Lawton, PMID 34882435); ESC 2023 NSTE-ACS (Byrne, PMID 37622670) — PMID:30153967
  • Cited evidence (PMID 34882435) — PMID:34882435
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 35105183) — PMID:35105183
  • Cited evidence (PMID 11815441) — PMID:11815441