12-phase flow (12)

1. 1FRAME
   NSTEMI-SCAD = non-atherosclerotic intramural hematoma → coronary sub-occlusion. CONSERVATIVE-FIRST management default unless instability. Demographics: women 40–60, peripartum, FMD, connective-tissue disorders. Plaque-rupture-based reasoning DOES NOT apply: lytics CONTRAINDICATED, thrombus aspiration AVOIDED, DAPT contested (ASA monotherapy increasingly preferred per DISCO PMID 33585917), AC NOT continued post-procedure, statin only if concomitant ASCVD.
   inputs: age, sex_and_pregnancy_status
   advance: SCAD probability stratified + paradigm shift documented
2. 2ENTRY
   Recognise NSTEMI-SCAD pre-test probability: peripartum / postpartum woman, known FMD or connective-tissue disorder, young woman with NSTEMI without conventional ASCVD risk factors, recent intense stressor
   inputs: fibromuscular_dysplasia_status, connective_tissue_disorder
   actions: acs_pathway
   advance: pre-test probability assigned + cath lab activation if criteria met
3. 3CONTEXT
   Pregnancy status (drives DAPT + radiation risk + lactation drug choice + BB selection), connective-tissue history with family vascular events, recent stressors (childbirth, intense exercise, emotional stress, retching), prior chest pain history, prior FMD diagnosis or imaging
   inputs: recent_emotional_or_physical_stressor, creatinine_egfr, cbc, hr
   advance: context complete + pregnancy / lactation status documented
4. 4RED_FLAGS
   Hemodynamic instability (SBP <90 / shock), ongoing ischemia, large-territory infarct (proximal LAD or LM), life-threatening arrhythmia → these override conservative-first paradigm and trigger PCI / CABG / MCS evaluation. Aortic dissection mimic must be ruled out before any heparin (CT-A if any concern).
   inputs: sbp
   actions: cardiogenic_shock, chest_pain
   advance: red flags screened + dissection mimic excluded
5. 5INITIAL_WORKUP
   ECG + serial hsTn + BMP + CBC + CXR + bedside echo with strain; cath with mandatory intracoronary imaging (IVUS or OCT) for any suspected SCAD case (Yip-Saw classification + intramural hematoma confirmation)
   inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, cbc, cor_angio_with_intracoronary_imaging, tte_with_strain
   actions: acs_pathway, panel.cardiac, panel.renal, panel.cbc
   advance: workup documented + Yip-Saw classification assigned
6. 6BRANCHING_WORKUP
   Intracoronary imaging (IVUS or OCT) when angiogram ambiguous (especially Yip-Saw type 3 mimicking atherosclerosis); FMD screen post-stabilization (renal + cerebrovascular CTA / MRA per Hayes 2018 PMID 29472380); embolic source workup if territory suggests; consider repeat cath at 4–6 weeks ONLY for recurrent symptoms (most heal spontaneously)
   inputs: cor_angio_with_intracoronary_imaging
   advance: SCAD subtype confirmed + management strategy decided
7. 7DIFFERENTIAL
   NSTEMI-SCAD vs atherosclerotic NSTEMI vs vasospastic angina (Prinzmetal) vs MINOCA (broader umbrella) vs takotsubo overlap vs aortic dissection extending to coronaries vs coronary embolism — intracoronary imaging is the discriminating modality
   advance: aetiology label committed
8. 8RISK_STRATIFICATION
   TIMI / GRACE / HEART scores LESS validated in SCAD — atypical demographics undervalue risk; intracoronary imaging findings (lesion location, length, distal vs proximal) are the dominant prognostic input; SCAI staging if shock complicates
   inputs: cha2ds2_vasc_factors, sbp, hr, creatinine_egfr
   actions: calc.heart
   advance: risk band documented + management arm selected
9. 9TREATMENT
   CONSERVATIVE management default (most heal in 4–6 weeks): admit telemetry, BB (carvedilol or metoprolol — wall-stress reduction; Class IIa ESC 2018 PMID 30033129), single antiplatelet (ASA monotherapy increasingly preferred per DISCO PMID 33585917) — DAPT NOT routine, AC NOT continued post-procedure. PCI ONLY if hemodynamic instability / ongoing ischemia / proximal large-territory lesion (technically challenging — guide-extension dissection risk; consider cutting balloon or conservative wiring). CABG if multivessel SCAD or PCI failed. AVOID lytics ABSOLUTELY (extension risk). AVOID thrombus aspiration. AVOID statin unless concomitant ASCVD or guideline-meeting LDL.
   inputs: sbp, creatinine_egfr, cbc
   advance: treatment strategy executed + paradigm-shift safeguards documented
10. 10DISPOSITION
    CICU 48–72 h for monitoring (extension risk peaks early); cardiology floor if stable; cardiac surgery on standby if proximal LAD or LM SCAD
    advance: unit assigned + extension surveillance plan documented
11. 11MONITORING
    Telemetry continuous first 48–72 h (extension risk window); serial echo for LV function recovery; serial hsTn to peak; repeat angio at 4–6 weeks NOT routine (most heal); only repeat for recurrent symptoms or pre-procedural planning if PCI deferred to outpatient setting
    inputs: hs_troponin_serial, tte_with_strain
    actions: panel.cardiac
    advance: extension + recovery surveillance documented
12. 12FOLLOWUP
    FMD screening (renal + cerebrovascular CTA / MRA per Hayes 2018 PMID 29472380); contraception counseling (avoid pregnancy ≥12 months post-SCAD; high recurrence risk in subsequent pregnancy — multidisciplinary high-risk obstetric + cardiology team mandatory if pregnancy desired); cardiac rehab (low-intensity programme — avoid heavy isometric exercise); genetics referral if connective-tissue disorder suspected; psychosocial support (recurrence anxiety + post-SCAD depression are common — PHQ-9 at every visit); long-term ASA + BB indefinitely
    advance: FMD screen + contraception + rehab + genetics + mental-health referrals booked