{
  "engine": {
    "id": "cpe-007",
    "code": "CPE-007",
    "name": "Cardiovascular Risk Pattern Engine",
    "version": "1.0.0",
    "url": "https://biod.ai/tools/cardiovascular",
    "status": "Executable specification v1.0.0, authored by Biod from the narrative CPE-007 specification and current guidelines. Reviewed by Dr. Vinicius Amaral, D.O. Not for clinical production use."
  },
  "notice": "Clinical decision support for licensed clinicians. Synthetic-data demonstration. Not FDA cleared. Physician adjudication required.",
  "rules": [
    {
      "id": "CV-SCOPE-01",
      "name": "Patients under 20 routed out",
      "group": "Scope and validity",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Patients under 20 routed out. Evaluates age_years below 20.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "age_years < 20"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Routing: pediatric lipid pathway"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Adult risk categories do not apply."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-scope-01"
    },
    {
      "id": "CV-SCOPE-02",
      "name": "Age bands that change the approach",
      "group": "Scope and validity",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Age bands that change the approach. Evaluates age 20 to 39 (10-year risk is not estimated).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "age 20 to 39 (10-year risk is not estimated)",
            "OR age 80 and over (limited trial evidence)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Age 20–39: lifetime risk, family history and severe hypercholesterolemia matter more than a 10-year estimate",
            "Age 80 and over: decisions are individualized"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not set a category."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018",
        "EV-ACCAHA-PREV-2019"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-scope-02"
    },
    {
      "id": "CV-SAFE-01",
      "name": "Possible acute cardiac or neurologic event",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Possible acute cardiac or neurologic event. Evaluates chest pain suggesting acute coronary syndrome OR stroke symptoms documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "chest pain suggesting acute coronary syndrome OR stroke symptoms documented"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Urgent assessment: this is not a risk-estimation context"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Routine outpatient risk review does not apply."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-PREV-2019"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-safe-01"
    },
    {
      "id": "CV-01",
      "name": "Established ASCVD",
      "group": "Risk category",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Established ASCVD. Evaluates clinical ASCVD documented (prior myocardial infarction, acute coronary syndrome, ischemic stroke or TIA, symptomatic peripheral arterial disease, revascularization).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "clinical ASCVD documented (prior myocardial infarction, acute coronary syndrome, ischemic stroke or TIA, symptomatic peripheral arterial disease, revascularization)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Secondary prevention: LDL-C lowering is a cornerstone",
            "Very high risk when two or more major ASCVD events, or one major event with two or more high-risk conditions"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Use the 2022 ACC pathway thresholds for adding non-statin therapy (LDL-C 55 mg/dL for very high risk, 70 otherwise)"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A category, not a treatment order."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018",
        "EV-ACC-ECDP-2022"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-01"
    },
    {
      "id": "CV-02",
      "name": "Severe hypercholesterolemia",
      "group": "Risk category",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Severe hypercholesterolemia. Evaluates LDL-C ≥ 190 mg/dL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "LDL-C ≥ 190 mg/dL"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Severe hypercholesterolemia: the 2018 guideline supports statin therapy without a risk estimate in adults 20–75"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Exclude secondary causes before assuming a primary disorder",
            "Consider familial hypercholesterolemia"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Guideline statement; the decision is the physician's."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-02"
    },
    {
      "id": "CV-03",
      "name": "Diabetes aged 40 to 75",
      "group": "Risk category",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Diabetes aged 40 to 75. Evaluates diabetes.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "diabetes",
            "age 40 to 75",
            "no established ASCVD"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Statin therapy is guideline-supported in this group; multiple risk factors or risk enhancers favor a stronger regimen"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A shared decision with the patient."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-03"
    },
    {
      "id": "CV-04",
      "name": "10-year ASCVD risk category",
      "group": "Risk category",
      "status": "active",
      "classification": "Priority 3",
      "summary": "10-year ASCVD risk category. Evaluates 10-year risk entered from the Pooled Cohort Equations, age 40 to 79, no established ASCVD.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "10-year risk entered from the Pooled Cohort Equations, age 40 to 79, no established ASCVD"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Low: below 5%",
            "Borderline: 5% to under 7.5%",
            "Intermediate: 7.5% to under 20%",
            "High: 20% or above"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Categories apply to the Pooled Cohort Equations only."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018",
        "EV-ACCAHA-PREV-2019"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-04"
    },
    {
      "id": "CV-04B",
      "name": "Risk estimate from a tool the categories do not cover",
      "group": "Risk category",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Risk estimate from a tool the categories do not cover. Evaluates 10-year risk entered from PREVENT or another tool.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "10-year risk entered from PREVENT or another tool"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "The 2018 category thresholds were set for the Pooled Cohort Equations; the physician applies the thresholds that suit the tool used"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "No category is assigned."
          ]
        }
      ],
      "evidence": [
        "EV-PREVENT-2024"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-04b"
    },
    {
      "id": "CV-05",
      "name": "Risk enhancers present",
      "group": "Risk modifiers",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Risk enhancers present. Evaluates borderline or intermediate risk.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "borderline or intermediate risk",
            "at least one risk enhancer: family history of premature ASCVD, persistent LDL-C 160 to 189, non-HDL-C 190 to 219, metabolic syndrome, chronic kidney disease, chronic inflammatory disease, history of preeclampsia or premature menopause, South Asian ancestry, persistent triglycerides ≥ 175, hs-CRP ≥ 2.0, Lp(a) ≥ 50 mg/dL or ≥ 125 nmol/L, apoB ≥ 130, ankle-brachial index < 0.9"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Risk enhancers favor a statin discussion in borderline and intermediate-risk adults"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Enhancers inform a shared decision; they do not mandate treatment."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-05"
    },
    {
      "id": "CV-06",
      "name": "Lipoprotein(a)",
      "group": "Risk modifiers",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Lipoprotein(a). Evaluates Lp(a) ≥ 50 mg/dL (≥ 125 nmol/L).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "Lp(a) ≥ 50 mg/dL (≥ 125 nmol/L)",
            "OR Lp(a) never measured"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Elevated Lp(a) is a risk enhancer",
            "One-time Lp(a) measurement is recommended by several societies"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Lp(a) is largely genetically determined; the value does not change with statins."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018",
        "EV-ESC-EAS-2019"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-06"
    },
    {
      "id": "CV-07",
      "name": "Apolipoprotein B",
      "group": "Risk modifiers",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Apolipoprotein B. Evaluates apoB ≥ 130 mg/dL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "apoB ≥ 130 mg/dL",
            "OR triglycerides 150 to 499 or diabetes or metabolic syndrome with apoB not measured"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "apoB ≥130 is a risk enhancer",
            "apoB can clarify particle burden when triglycerides are raised"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A marker, not a target set by this rule."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018",
        "EV-NLA-2015"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-07"
    },
    {
      "id": "CV-08",
      "name": "High-sensitivity CRP",
      "group": "Risk modifiers",
      "status": "active",
      "classification": "Priority 6",
      "summary": "High-sensitivity CRP. Evaluates hs-CRP ≥ 2.0 mg/L, persistent.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "hs-CRP ≥ 2.0 mg/L, persistent"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "hs-CRP is a risk enhancer that informs a shared decision"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "The JUPITER population does not define a treatment rule here."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018",
        "EV-JUPITER-2008"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-08"
    },
    {
      "id": "CV-09",
      "name": "Coronary artery calcium",
      "group": "Risk modifiers",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Coronary artery calcium. Evaluates borderline or intermediate risk with an uncertain decision.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "borderline or intermediate risk with an uncertain decision",
            "coronary artery calcium score entered"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Score 0: lower risk, treatment may reasonably be deferred (except diabetes, family history of premature ASCVD, smoking)",
            "Score 1 to 99: favors a statin, especially from age 55",
            "Score 100 or more, or at/above the 75th percentile: favors a statin"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A decision aid for the shared discussion."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-09"
    },
    {
      "id": "CV-10",
      "name": "LDL-C above the pathway threshold on treatment",
      "group": "Monitoring",
      "status": "active",
      "classification": "Priority 3",
      "summary": "LDL-C above the pathway threshold on treatment. Evaluates lipid-lowering therapy active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "lipid-lowering therapy active",
            "established ASCVD",
            "LDL-C ≥ 70 mg/dL (≥ 55 mg/dL for very high risk)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "LDL-C is above the 2022 ACC pathway threshold for considering added therapy"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Review adherence and tolerability",
            "Physician to consider added therapy per the pathway"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not name a drug."
          ]
        }
      ],
      "evidence": [
        "EV-ACC-ECDP-2022"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-10"
    },
    {
      "id": "CV-11",
      "name": "Monitoring gap",
      "group": "Monitoring",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Monitoring gap. Evaluates lipid-lowering therapy active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "lipid-lowering therapy active",
            "no LDL-C measured in the last 12 months"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Follow-up lipid measurement is overdue"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A prompt."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-11"
    },
    {
      "id": "CV-12",
      "name": "Severe hypertriglyceridemia",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Severe hypertriglyceridemia. Evaluates triglycerides ≥ 1000 mg/dL (urgent).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "triglycerides ≥ 1000 mg/dL (urgent)",
            "triglycerides 500 to 999 mg/dL (priority)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Risk of pancreatitis rises with severe hypertriglyceridemia"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Cardiovascular risk estimation is secondary here."
          ]
        }
      ],
      "evidence": [
        "EV-ACC-TG-2021"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-12"
    },
    {
      "id": "CV-13",
      "name": "Secondary causes of dyslipidemia",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Secondary causes of dyslipidemia. Evaluates LDL-C ≥ 190 OR triglycerides ≥ 500 OR a marked recent change.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "LDL-C ≥ 190 OR triglycerides ≥ 500 OR a marked recent change"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Review hypothyroidism, diabetes, nephrotic syndrome, cholestasis, obesity, alcohol and medications before assuming a primary disorder"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A checklist."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-13"
    },
    {
      "id": "CV-14",
      "name": "Familial hypercholesterolemia suspected",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Familial hypercholesterolemia suspected. Evaluates LDL-C ≥ 190 mg/dL OR tendon xanthomas OR a family member with known familial hypercholesterolemia.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "LDL-C ≥ 190 mg/dL OR tendon xanthomas OR a family member with known familial hypercholesterolemia"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Consider familial hypercholesterolemia: clinical scoring (for example the Dutch Lipid Clinic Network) and cascade screening of relatives"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not diagnose."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-14"
    },
    {
      "id": "CV-15",
      "name": "Modifiable risk factors present",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 6",
      "summary": "Modifiable risk factors present. Evaluates current smoking OR blood pressure ≥ 130/80 mmHg OR BMI ≥ 30.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "current smoking OR blood pressure ≥ 130/80 mmHg OR BMI ≥ 30"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Modifiable factors are present and affect risk independent of lipids"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A list."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-PREV-2019"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-15"
    },
    {
      "id": "CV-MISS-01",
      "name": "Data needed to place the patient",
      "group": "Missing data",
      "status": "active",
      "classification": "Priority 8",
      "summary": "Data needed to place the patient. Evaluates no lipid panel OR no risk estimate where one is needed.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "no lipid panel OR no risk estimate where one is needed"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "A lipid panel and, for primary prevention, a 10-year risk from a validated calculator are needed"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Names what is needed."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-miss-01"
    },
    {
      "id": "CV-CALC-01",
      "name": "Derived value",
      "group": "Calculations",
      "status": "module",
      "classification": "Context",
      "summary": "Derived value. Evaluates total cholesterol and HDL-C available.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "total cholesterol and HDL-C available"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Non-HDL cholesterol = total cholesterol − HDL-C"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Informational."
          ]
        }
      ],
      "evidence": [
        "EV-ACCAHA-CHOL-2018"
      ],
      "url": "https://biod.ai/tools/cardiovascular/rules/cv-calc-01"
    }
  ],
  "evidence": [
    {
      "id": "EV-ACCAHA-CHOL-2018",
      "citation": "Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Circulation. 2019;139(25):e1082-e1143.",
      "supports": [
        "Risk categories, risk enhancers, statin benefit groups and the coronary-calcium decision aid",
        "Very-high-risk ASCVD definition"
      ]
    },
    {
      "id": "EV-ACC-ECDP-2022",
      "citation": "Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of ASCVD Risk. J Am Coll Cardiol. 2022;80(14):1366-1418.",
      "supports": [
        "LDL-C thresholds of 55 and 70 mg/dL for considering added therapy in ASCVD"
      ]
    },
    {
      "id": "EV-ACCAHA-PREV-2019",
      "citation": "Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11):e596-e646.",
      "supports": [
        "Primary prevention approach, risk estimation and modifiable risk factors"
      ]
    },
    {
      "id": "EV-PREVENT-2024",
      "citation": "Khan SS, Matsushita K, Sang Y, et al. Development and Validation of the American Heart Association's PREVENT Equations. Circulation. 2024;149(6):430-449.",
      "supports": [
        "Race-free risk equations whose output is not interchangeable with the Pooled Cohort Equations"
      ]
    },
    {
      "id": "EV-ESC-EAS-2019",
      "citation": "Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2020;41(1):111-188.",
      "supports": [
        "At least one lifetime measurement of Lp(a)"
      ]
    },
    {
      "id": "EV-NLA-2015",
      "citation": "Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: Part 1. J Clin Lipidol. 2015;9(2):129-169.",
      "supports": [
        "apoB as a marker of atherogenic particle number, particularly with raised triglycerides"
      ]
    },
    {
      "id": "EV-JUPITER-2008",
      "citation": "Ridker PM, Danielson E, Fonseca FAH, et al. Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein. N Engl J Med. 2008;359(21):2195-2207.",
      "supports": [
        "hs-CRP ≥2 mg/L identified a population in whom a statin lowered events despite a low LDL-C"
      ]
    },
    {
      "id": "EV-ACC-TG-2021",
      "citation": "Virani SS, Morris PB, Agarwala A, et al. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia. J Am Coll Cardiol. 2021;78(9):960-993.",
      "supports": [
        "Severe hypertriglyceridemia: ≥500 mg/dL carries a pancreatitis risk; ≥1000 mg/dL needs urgent attention"
      ]
    }
  ]
}