This handout is for nstemi from spontaneous coronary artery dissection (scad). Your care team identified this based on: peripartum / postpartum woman (within 12 weeks delivery) with ischemic chest pain + hstn rise/fall + non-st-elevation ecg — high scad probability.
Other reasons your team may use this plan: coronary angiogram in nste-acs workup showing yip-saw type 1 (multiple radiolucent lumens + contrast staining), type 2 (long diffuse smooth stenosis), or type 3 (focal stenosis mimicking atherosclerosis) → scad; patient with known fibromuscular dysplasia, ehlers-danlos vascular type, marfan, loeys-dietz, or polycystic kidney disease presenting with nstemi — pre-test probability of scad high; mandatory intracoronary imaging at cath; woman aged 40–60 presenting with nstemi without conventional ascvd risk factors (no dm, no htn, no smoking, no hyperlipidemia, no family history) — pre-test probability of scad elevated per mayo scad registry.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| aspirin | 81 mg daily (no high-dose load if conservative path likely) OR 162–325 mg load if PCI | PO | daily indefinitely if conservative; daily × 12 mo per ACS protocol if PCI | ESC 2018 SCAD position (PMID 30033129); DISCO trial (PMID 33585917) — ASA monotherapy non-inferior to DAPT in conservative SCAD; ASA continued indefinitely per Mayo SCAD registry consensus (Tweet PMID 22800851) |
| carvedilol | 3.125 mg BID titrate to max tolerated (target HR 60–80) | PO | BID indefinitely | ESC 2018 SCAD position Class IIa (PMID 30033129); Mayo SCAD registry observational data show ~20% relative risk reduction in recurrence; reduces wall stress on healing dissection plane |
| metoprolol | metoprolol succinate 25–50 mg PO daily titrate (target HR 60–80); preferred in pregnancy / lactation | PO | daily | Beta1-selective; safer in pregnancy/lactation per ESC 2018 SCAD position; metoprolol succinate or labetalol preferred over carvedilol when pregnancy considerations dominate |
| clopidogrel | 300 mg load → 75 mg daily | PO | daily × duration determined case-by-case (typically 1–12 months if PCI) | Add P2Y12 ONLY if PCI performed (mandatory DAPT post-stent) OR intracoronary thrombus on OCT/IVUS; clopidogrel preferred over ticagrelor / prasugrel in SCAD due to lower bleeding extension risk per Mayo SCAD registry consensus |
| unfractionated heparin | 70–100 U/kg IV bolus at PCI; NOT continued post-cath in conservative SCAD | IV | bolus only at PCI; discontinue post-procedure | AHA 2025 ACS Class I for PCI; in SCAD specifically, AC NOT continued post-procedure to avoid hematoma extension — ESC 2018 SCAD position |
| atorvastatin | 40–80 mg daily | PO | daily | NOT routinely indicated in SCAD (no plaque rupture); reserve for patients with concomitant ASCVD or 2018 ACC/AHA guideline-meeting LDL — different from atherosclerotic NSTEMI default per ESC 2018 SCAD position (PMID 30033129) |
| lisinopril | 2.5–5 mg daily titrate | PO | daily | GDMT initiation per ACC/AHA 2022 HF Class I if LVEF reduced post-SCAD-MI; otherwise not routinely needed |
Plan: NSTEMI-SCAD conservative-first regimen — overrides parent cardio.nstemi.core.v1 DAPT default; uses ASA monotherapy + BB; PCI / AC reserved for instability; lytics + thrombus aspiration ABSOLUTELY CONTRAINDICATED — ESC 2018 SCAD position (Adlam PMID 30033129); Hayes 2018 ACC SCAD Scientific Statement (PMID 29472380); DISCO trial (Cerrato EHJ 2021 PMID 33585917)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: ESC 2018 SCAD position paper (Adlam EHJ 2018 PMID 30033129) + Hayes 2018 ACC SCAD Scientific Statement (PMID 29472380) + 2025 ACC/AHA ACS Guideline (Rao) + DISCO trial (Cerrato EHJ 2021 PMID 33585917) + Mayo Clinic SCAD registry