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cardio.nstemi.type2.v1PRODUCTION
cardio.nstemi.type2.v1

Type-2 MI (demand ischemia, no plaque rupture)

cardiologyacuteadult
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12/12 authored

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

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Detailed

Confirm type-2 MI per 4th UDMI 2018 PMID 30153967 — hsTn rise from supply-demand mismatch (sepsis, anemia, tachyarrhythmia, hypoxia, hypotension, severe HTN, drug toxicity) WITHOUT ischemic ECG, WITHOUT clinical ACS syndrome, WITHOUT plaque-rupture imaging

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Type-2 vs type-1 distinction documented; trigger identified

Patient inputs (13)

Type-2 MI commoner in elderly + multimorbid; comorbidity-driven prognosis per DeFilippis PMID 30689349

Tachyarrhythmia trigger identification; rate control is primary therapy

Sepsis screening — most common type-2 trigger

Hypoxia trigger identification (e.g., COPD exacerbation, severe pneumonia, PE)

Known obstructive CAD changes management — selective cath if ongoing ischemia post-trigger correction per ACC/AHA 2025

0/1-h or 0/3-h ESC 2023 algorithm — pattern in type-2 typically slow rise/plateau without sharp peak; distinguishes from type-1 acute coronary thrombus

Hgb identifies anemia trigger; WBC for sepsis trigger; platelets for HIT/DIC

Sepsis / shock screening — drives source-control timing

Baseline kidney function — many type-2 triggers (sepsis, hypotension) cause concurrent AKI per KDIGO 2026

Confirm absence of ischemic ECG; detect sinus tachycardia / AF with RVR / strain pattern (PE)

Pneumonia, edema, PTX, dissection screen — many trigger sources

Hypotension itself a trigger (decreases coronary perfusion); also gates whether this is type-2 vs type-1 with cardiogenic shock

Sympathomimetic toxicity is a type-2 trigger; cocaine chest pain has unique workflow per AHA 2008

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Severity triggers (5)

5 need judgement
  • informationallife_threateningseptic_shock_with_type2_mi
    Septic shock + hsTn rise — type-2 MI driven by sepsis; sepsis bundle is primary therapy per SSC 2026
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_anemia_with_type2_mi
    Hgb <7 (or <8 with cardiac symptoms) + hsTn rise — type-2 MI driven by anemia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretachyarrhythmia_demand_ischemia
    AF with RVR / SVT / sustained VT with HR >150 + hsTn rise — type-2 MI from rate-driven demand ischemia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverereclassification_to_type1_acs
    New dynamic ECG OR clinical ACS syndrome appears during type-2 admission — pathology now suggests type-1 plaque rupture
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecocaine_or_methamphetamine_chest_pain
    Cocaine or methamphetamine use with chest pain + hsTn rise — sympathomimetic toxicity drives type-2 MI; AVOID β-blocker
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Type-2 MI trigger-targeted therapy — antithrombotic only if known obstructive CAD per ACC/AHA 2025; treat the trigger primarily per 4th UDMI 2018 PMID 30153967
axis: type2_mi_trigger_targeted_therapy
Selected axis "Type-2 MI trigger-targeted therapy — antithrombotic only if known obstructive CAD per ACC/AHA 2025; treat the trigger primarily per 4th UDMI 2018 PMID 30153967" by default fallback (first axis)
  • aspirin
    comorbidity specific
    antiplatelet_cox1
    81 mg daily • PO • daily IF known obstructive CAD; otherwise NO antiplatelet for type-2 MI alone
    triggers: type_2_mi_with_known_obstructive_cad
    ACC/AHA 2025 — treat trigger primarily; antiplatelet only if obstructive CAD known. Type-2 MI 1-yr mortality 37% vs type-1 28% but driven by comorbidity not by deferred antithrombotic per DeFilippis PMID 30689349
    rxcui 1191
  • atorvastatin
    comorbidity specific
    statin_high_intensity
    40-80 mg daily • PO • daily IF known obstructive CAD or independent ASCVD indication
    triggers: type_2_mi_with_known_cad, independent_ascvd_indication
    PROVE-IT PMID 15007110 — benefit established in type-1 ACS; type-2 use depends on CAD status not on type-2 event itself per ACC/AHA 2025
    rxcui 83367
  • metoprolol_tartrate
    comorbidity specific
    beta_blocker_cardioselective
    5 mg IV q5 min × 3 if AF with RVR + stable; OR PO 25 mg BID • IV/PO • titrate to HR <110
    triggers: af_with_rvr_demand_ischemia, sympathomimetic_trigger_excluding_cocaine
    Rate control for tachyarrhythmia trigger; AVOID in cocaine-induced (unopposed alpha) per AHA 2008 cocaine chest pain pathway
    rxcui 6918
  • diltiazem
    comorbidity specific
    calcium_channel_blocker_non_dhp
    0.25 mg/kg IV bolus → 5-15 mg/h infusion • IV • continuous titrate to HR <110
    triggers: af_with_rvr_when_bb_contraindicated, cocaine_associated_tachycardia_with_caution
    Rate control alternative when β-blocker contraindicated; 2024 AHA AF guideline
    rxcui 3443
  • norepinephrine
    comorbidity specific
    vasopressor
    0.05-0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: septic_shock_trigger, distributive_shock
    SOAP-II first-line vasopressor; restoring perfusion corrects demand-supply mismatch driving type-2 MI
    rxcui 7512

outpatient playbook — drug actions (3)

  1. 1. optimise comorbidity GDMT
    per comorbidity • PO • as scheduled
    trigger: Comorbidity optimisation
    Comorbidity drives type-2 mortality per DeFilippis PMID 30689349
  2. 2. add aspirin 81 + statin if stress test confirms obstructive CAD
    aspirin 81 + atorvastatin 40-80 • PO • daily
    trigger: Newly identified obstructive CAD
    ACC/AHA 2025 secondary prevention if CAD confirmed
  3. 3. address trigger recurrence prevention
    rate control for AF (BB / NDCCB) / iron supplementation / preventive abx if recurrent UTI / inhaler optimisation if COPD • PO/SC • as scheduled
    trigger: Trigger pattern identified
    Prevent recurrent demand ischemia via underlying disease control

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: hsTn rise/fall in patient with sepsis, severe anemia, tachyarrhythmia, hypoxia, hypotension, severe HTN, or drug toxicity (4th UDMI 2018); hsTn elevation WITHOUT ischemic ECG and without clinical ACS syndrome — supports type-2 vs type-1; Sepsis or septic shock with hsTn rise — most common type-2 trigger; treat sepsis bundle first per SSC 2026.

Objective

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

Assessment

**Type-2 MI (demand ischemia, no plaque rupture)** (cardio.nstemi.type2.v1).
Phenotype framing: Type-2 MI vs type-1 NSTEMI (plaque rupture) vs Takotsubo vs myocarditis vs strain (PE, severe HTN) per 4th UDMI 2018 PMID 30153967
Scope: Confirm type-2 MI per 4th UDMI 2018 PMID 30153967 — hsTn rise from supply-demand mismatch (sepsis, anemia, tachyarrhythmia, hypoxia, hypotension, severe HTN, drug toxicity) WITHOUT ischemic ECG, WITHOUT clinical ACS syndrome, WITHOUT plaque-rupture imaging

No severity triggers fired against current inputs.

Plan

Regimen axis: **Type-2 MI trigger-targeted therapy — antithrombotic only if known obstructive CAD per ACC/AHA 2025; treat the trigger primarily per 4th UDMI 2018 PMID 30153967**.
1. aspirin 81 mg daily PO daily IF known obstructive CAD; otherwise NO antiplatelet for type-2 MI alone (antiplatelet_cox1, comorbidity specific) — ACC/AHA 2025 — treat trigger primarily; antiplatelet only if obstructive CAD known. Type-2 MI 1-yr mortality 37% vs type-1 28% but driven by comorbidity not by deferred antithrombotic per DeFilippis PMID 30689349
2. atorvastatin 40-80 mg daily PO daily IF known obstructive CAD or independent ASCVD indication (statin_high_intensity, comorbidity specific) — PROVE-IT PMID 15007110 — benefit established in type-1 ACS; type-2 use depends on CAD status not on type-2 event itself per ACC/AHA 2025
3. metoprolol_tartrate 5 mg IV q5 min × 3 if AF with RVR + stable; OR PO 25 mg BID IV/PO titrate to HR <110 (beta_blocker_cardioselective, comorbidity specific) — Rate control for tachyarrhythmia trigger; AVOID in cocaine-induced (unopposed alpha) per AHA 2008 cocaine chest pain pathway
4. diltiazem 0.25 mg/kg IV bolus → 5-15 mg/h infusion IV continuous titrate to HR <110 (calcium_channel_blocker_non_dhp, comorbidity specific) — Rate control alternative when β-blocker contraindicated; 2024 AHA AF guideline
5. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor, comorbidity specific) — SOAP-II first-line vasopressor; restoring perfusion corrects demand-supply mismatch driving type-2 MI

Setting playbook (outpatient) — Long-term type-2 MI surveillance — outpatient cardiology with stress test or CCTA result; comorbidity optimisation; transition to chronic disease management
6. optimise comorbidity GDMT per comorbidity PO as scheduled — Comorbidity optimisation (Comorbidity drives type-2 mortality per DeFilippis PMID 30689349)
7. add aspirin 81 + statin if stress test confirms obstructive CAD aspirin 81 + atorvastatin 40-80 PO daily — Newly identified obstructive CAD (ACC/AHA 2025 secondary prevention if CAD confirmed)
8. address trigger recurrence prevention rate control for AF (BB / NDCCB) / iron supplementation / preventive abx if recurrent UTI / inhaler optimisation if COPD PO/SC as scheduled — Trigger pattern identified (Prevent recurrent demand ischemia via underlying disease control)

Non-pharmacologic actions:
- Reinforce daily BP + symptom log
- Cardiac rehab if CAD confirmed
- Smoking cessation reinforcement
- Mediterranean / DASH diet counseling if CAD or HTN

AVOID / contraindication checks:
- Antiplatelet not routine in type2 mi without known obstructive cad (ACC/AHA 2025)
- Beta blocker block if cocaine induced (AHA 2008 — unopposed alpha)
- Beta blocker block if cardiogenic shock (ACC/AHA 2025)
- Transfuse to mint threshold (Carson NEJM 2023 — restrictive Hgb 7 8 in cardiac disease)

Monitoring

Regimen monitoring:
- Trend hsTn to peak then normalisation (confirms trigger correction)
- Serial lactate q2-4 h if shock trigger
- Continuous ECG to detect new ischemic changes that would re-classify to type-1
- Hgb q12 h if anemia trigger; transfuse to MINT threshold per Carson NEJM 2023
- Trigger-specific (cultures + source control for sepsis; toxicology for drug; thyroid for storm)

Setting (outpatient) monitoring:
- BMP at week 4
- Lipid panel — if obstructive CAD, target LDL <70 (or <55 very-high-risk)
- A1c at 3 mo if newly diagnosed DM2
- Trigger-specific (Hgb trend, AF rhythm, HF NYHA)

Follow-up plan: Outpatient cardiology + stress test or CCTA if recovers — to detect underlying obstructive CAD that contributed to demand-supply ischemia. Optimise comorbidities (sepsis recovery, HF, CKD, DM)
- Close-out criterion: Outpatient cardiology + stress workup booked

Monitoring phase: Serial hsTn to confirm trigger correction normalises trend; trend lactate, vitals, trigger-specific markers; re-screen ECG for new ischemic changes that would re-classify to type-1

Disposition

Current setting: outpatient — Long-term type-2 MI surveillance — outpatient cardiology with stress test or CCTA result; comorbidity optimisation; transition to chronic disease management

Disposition criteria:
- Formal handoff to chronic CAD engine if obstructive CAD confirmed; otherwise long-term comorbidity management with cardiology surveillance

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED for serial hsTn + ECG
- Recurrent trigger → trigger-specific re-eval
- Stress test positive for obstructive CAD → cardiology + cath consideration

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Septic shock + hsTn rise — type-2 MI driven by sepsis; sepsis bundle is primary therapy per SSC 2026
- [SEVERE] Hgb <7 (or <8 with cardiac symptoms) + hsTn rise — type-2 MI driven by anemia
- [SEVERE] AF with RVR / SVT / sustained VT with HR >150 + hsTn rise — type-2 MI from rate-driven demand ischemia

Citations

- 4th Universal Definition of MI 2018 (Thygesen Circulation 2018, PMID 30153967); 2025 ACC/AHA ACS Guideline (Rao); ESC 2023 NSTE-ACS Guideline (Byrne, PMID 37622670) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)
- Cited evidence (PMID 30689349) [PMID:30689349](https://pubmed.ncbi.nlm.nih.gov/30689349/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 34669377) [PMID:34669377](https://pubmed.ncbi.nlm.nih.gov/34669377/)
- Cited evidence (PMID 19720857) [PMID:19720857](https://pubmed.ncbi.nlm.nih.gov/19720857/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 4th Universal Definition of MI 2018 (Thygesen Circulation 2018, PMID 30153967); 2025 ACC/AHA ACS Guideline (Rao); ESC 2023 NSTE-ACS Guideline (Byrne, PMID 37622670) — PMID:30153967
  • Cited evidence (PMID 30689349) — PMID:30689349
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 34669377) — PMID:34669377
  • Cited evidence (PMID 19720857) — PMID:19720857