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cardio.stemi.scad.v1

STEMI from spontaneous coronary artery dissection (SCAD)

cardiologyacuteadultpregnancyacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E etiology variant of cardio.stemi.core.v1 — non-atherosclerotic STEMI from spontaneous coronary artery dissection (SCAD). Demographics: peripartum / postpartum women, fibromuscular dysplasia (20-50% of SCAD), connective tissue disorders. CONSERVATIVE management default per ESC 2018 SCAD position (PMID 30033129) — most heal spontaneously; PCI reserved for hemodynamic instability / large infarct. OVERRIDES parent antiplatelet (single agent vs DAPT), AC (none post-procedure), statin (only if concomitant ASCVD), and revascularization (conservative-first) defaults. Inherits parent for shock management and HFrEF GDMT only. Long-term: FMD screening (renal + cerebrovascular CTA / MRA), contraception counseling (avoid pregnancy ≥12 mo post-SCAD), genetics referral, cardiac rehab (low-intensity programme), mental-health support. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (3)

  • symptom
    Peripartum / postpartum woman with ischemic chest pain + ST elevation — high SCAD probability
    peripartum_chest_pain_with_st_elevation
  • imaging
    Coronary angiogram showing Yip-Saw type 1 (contrast staining + multiple radiolucent lumens), type 2 (long diffuse smooth stenosis), or type 3 (focal stenosis mimicking atherosclerosis) → SCAD
    angio_yip_saw_classification
  • history
    Patient with known FMD, Ehlers-Danlos, Marfan, or Loeys-Dietz presenting with STEMI — pre-test probability of SCAD high
    fmd_or_connective_tissue_disorder_with_st_elevation

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    SCAD skews younger (mean ~44 years) than atherosclerotic ACS; >90% are women
  • sex_and_pregnancy_statusrequired
    demographic • used at CONTEXT
    Peripartum / postpartum women are the highest-incidence SCAD subgroup; pregnancy status drives both diagnosis probability and treatment choices (DAPT contraindications)
  • fibromuscular_dysplasia_statusrequired
    history • used at CONTEXT
    FMD coexists in 20-50% of SCAD; presence raises pre-test probability and changes long-term surveillance (renal + cerebrovascular FMD screening)
  • connective_tissue_disorder
    history • used at CONTEXT
    Ehlers-Danlos vascular type, Marfan, Loeys-Dietz raise SCAD probability and change long-term genetics referral
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic stability drives the conservative-vs-PCI decision; SBP <90 + ongoing ischemia → PCI despite extension risk
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    ST elevation pattern + territory; SCAD often presents with NSTEMI but STEMI possible with full-thickness occlusion
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Quantifies infarct burden; higher troponin + larger territory → tip toward PCI vs conservative
  • creatininerequired
    lab • used at CONTEXT
    eGFR for contrast + DOAC dosing if PCI performed
  • cor_angiorequired
    imaging • used at TREATMENT
    Diagnostic gold standard combined with intracoronary imaging; Yip-Saw classification determines SCAD subtype + management
  • ivus_or_oct
    imaging • used at TREATMENT
    Intravascular imaging (IVUS or OCT) confirms intramural hematoma + false lumen — gold standard when angiogram is ambiguous; OCT preferred for resolution
  • echo_post_admissionrequired
    imaging • used at MONITORING
    LVEF + regional wall motion; serial echo for thrombus / aneurysm if conservative management

12-phase flow (10)

  1. 1FRAME
    SCAD = non-atherosclerotic intramural hematoma → coronary occlusion. Conservative management preferred unless instability. Demographics: peripartum women, FMD, connective tissue disorders. Plaque-rupture-based reasoning DOES NOT apply; DAPT is contested.
    inputs: age, sex_and_pregnancy_status
    advance: SCAD probability stratified
  2. 2ENTRY
    Recognise SCAD pre-test probability: peripartum / postpartum woman, known FMD, connective tissue disorder, young woman without ASCVD risk factors with chest pain
    inputs: fibromuscular_dysplasia_status
    advance: pre-test probability assigned
  3. 3CONTEXT
    Pregnancy status (drives DAPT + radiation risk + lactation drug choice), connective-tissue history, family history of vascular events, recent stressors (childbirth, intense exercise, emotional stress)
    inputs: connective_tissue_disorder, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Hemodynamic instability (SBP <90 / shock), ongoing ischemia, large-territory infarct (anterior or LM), life-threatening arrhythmia → these override conservative-first paradigm and trigger PCI / CABG / MCS
    inputs: sbp
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + CBC + CXR + bedside echo; emergent cath for diagnosis + Yip-Saw classification
    inputs: ecg, troponin, echo_post_admission
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Intracoronary imaging (IVUS / OCT) when angiogram ambiguous (especially Yip-Saw type 3 mimicking atherosclerosis); FMD screen post-stabilization (renal + cerebrovascular CTA / MRA)
    inputs: cor_angio, ivus_or_oct
    advance: SCAD subtype confirmed + management decided
  7. 7TREATMENT
    CONSERVATIVE management default (most heal in weeks): admit telemetry, BB, single antiplatelet (ASA) — DAPT NOT routinely used. PCI ONLY if hemodynamic instability / ongoing ischemia / large infarct (technically challenging — guide-extension dissection risk). CABG if multivessel or PCI failed.
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: treatment strategy executed
  8. 8DISPOSITION
    CICU 48-72 h for monitoring (extension risk peaks early); cardiology floor if stable
    advance: unit assigned + extension surveillance plan documented
  9. 9MONITORING
    Telemetry continuous (extension risk); serial echo for LV function recovery; repeat angio at 4-6 weeks NOT routine (most heal); only repeat for recurrent symptoms
    inputs: echo_post_admission
    actions: panel.cardiac
    advance: extension + recovery surveillance documented
  10. 10FOLLOWUP
    FMD screening (renal + cerebrovascular CTA / MRA); contraception counseling (avoid pregnancy if recent SCAD; relative contraindication for ~12 months post-SCAD); cardiac rehab (low-intensity); genetics referral if connective-tissue disorder suspected; psychosocial support (recurrence anxiety is common)
    advance: FMD screen + contraception + rehab + genetics referrals booked