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cardio.nstemi.scad-related.v1PRODUCTION
cardio.nstemi.scad-related.v1

NSTEMI from spontaneous coronary artery dissection (SCAD)

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

Current phase

Frame

Detailed

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.

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SCAD probability stratified + paradigm shift documented

Patient inputs (14)

NSTEMI-SCAD skews younger than atherosclerotic NSTEMI (mean ~50 years vs ~67); >90% are women — drives pre-test probability

Peripartum / postpartum (within 12 weeks of delivery) is the highest-incidence SCAD subgroup; pregnancy status drives diagnosis probability AND treatment choices (DAPT contraindications, statin avoidance, BB selection metoprolol vs labetalol)

FMD coexists in 50–70% of SCAD per Saw 2016 (PMID 27045207); presence raises pre-test probability AND mandates long-term renal + cerebrovascular CTA / MRA surveillance

Tachycardia raises wall stress + extension risk; aggressive HR control with BB is part of conservative regimen (target HR 60–80)

Confirms NSTE-ACS pattern (no persistent ST elevation; T-wave inversion / dynamic ST depression / new bundle branch block); transient ST changes during chest pain raise vasospasm overlap consideration

Defines NSTEMI per 4th UDMI (PMID 30153967) rise/fall criteria; quantifies infarct burden and informs conservative-vs-PCI decision (very large troponin rise + large territory tips toward PCI)

eGFR for contrast load at cath; DOAC dosing if AC bridging needed (rare in SCAD); KDIGO 2021 race-free baseline

Baseline before any antiplatelet / AC; rules out anemia mimic for ischemia

Diagnostic gold standard combined with intracoronary imaging (IVUS or OCT); Yip-Saw classification determines SCAD subtype; OCT preferred for resolution to detect intramural hematoma + false lumen

LVEF + regional wall motion + GLS at admission; serial echo for LV function recovery during conservative monitoring

Hemodynamic stability drives the conservative-vs-PCI decision; SBP <90 + ongoing ischemia overrides conservative-first paradigm and triggers PCI / CABG / MCS despite extension risk

AF stroke risk if AF detected post-SCAD; rarely needed in this young population but baseline assessment standard

Ehlers-Danlos vascular type, Marfan, Loeys-Dietz, polycystic kidney disease raise SCAD probability AND drive genetics referral and family screening

Intense exercise (Valsalva, isometric), emotional stress, retching, or recent childbirth are common SCAD triggers — informs counseling and recurrence prevention

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningnstemi_scad_with_dissection_extension_on_repeat_cath
    Recurrent chest pain post-conservative-SCAD + repeat angio shows dissection extension or new false lumen
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnstemi_scad_with_hemodynamic_instability_requiring_pci
    NSTEMI-SCAD + SBP <90 / shock / large-territory infarct → conservative paradigm overridden, emergent PCI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnstemi_scad_lytics_administered_in_error
    Lytic therapy (alteplase, tenecteplase) administered before SCAD diagnosis confirmed — high risk of dissection extension and intramural hematoma propagation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenstemi_scad_recurrence_in_first_year
    New chest pain + ECG / troponin changes within 12 months of index SCAD — recurrence rate ~10–30% in observational series (Mayo SCAD registry)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenstemi_scad_with_planned_or_actual_pregnancy
    SCAD survivor with planned pregnancy OR new pregnancy detected within 12 months of SCAD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenstemi_scad_with_dapt_initiated_no_pci_no_thrombus
    DAPT initiated (P2Y12 added to ASA) in conservatively-managed NSTEMI-SCAD without PCI and without intracoronary thrombus on OCT/IVUS — bleeding risk without clear benefit
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

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)
axis: nstemi_scad_conservative_first_phenotype
Selected axis "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)" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    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
    triggers: nstemi_scad_confirmed
    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)
    rxcui 243670
  • carvedilol
    first line
    beta_blocker_nonselective_alpha1
    3.125 mg BID titrate to max tolerated (target HR 60–80) • PO • BID indefinitely
    triggers: nstemi_scad_confirmed, no_decompensated_HF
    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
    rxcui 20352
  • metoprolol
    first line
    beta_blocker_beta1_selective
    metoprolol succinate 25–50 mg PO daily titrate (target HR 60–80); preferred in pregnancy / lactation • PO • daily
    triggers: nstemi_scad_in_pregnancy_or_lactation, carvedilol_intolerant
    Beta1-selective; safer in pregnancy/lactation per ESC 2018 SCAD position; metoprolol succinate or labetalol preferred over carvedilol when pregnancy considerations dominate
    rxcui 6918
  • clopidogrel
    comorbidity specific
    p2y12_inhibitor
    300 mg load → 75 mg daily • PO • daily × duration determined case-by-case (typically 1–12 months if PCI)
    triggers: nstemi_scad_with_pci_performed, nstemi_scad_with_intraluminal_thrombus_on_oct
    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
    rxcui 309362
  • unfractionated heparin
    rescue
    anticoagulant_indirect
    70–100 U/kg IV bolus at PCI; NOT continued post-cath in conservative SCAD • IV • bolus only at PCI; discontinue post-procedure
    triggers: nstemi_scad_with_pci_performed
    AHA 2025 ACS Class I for PCI; in SCAD specifically, AC NOT continued post-procedure to avoid hematoma extension — ESC 2018 SCAD position
    rxcui 5224
  • atorvastatin
    comorbidity specific
    statin_high_intensity
    40–80 mg daily • PO • daily
    triggers: nstemi_scad_with_concomitant_ascvd, nstemi_scad_with_lipid_levels_meeting_2018_acc_aha_indication
    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)
    rxcui 83367
  • lisinopril
    comorbidity specific
    ace_inhibitor
    2.5–5 mg daily titrate • PO • daily
    triggers: nstemi_scad_with_lv_dysfunction_ef_below_40, nstemi_scad_with_anterior_territory_large_infarct
    GDMT initiation per ACC/AHA 2022 HF Class I if LVEF reduced post-SCAD-MI; otherwise not routinely needed
    rxcui 29046

outpatient playbook — drug actions (1)

  1. 1. continue ASA + carvedilol indefinitely
    rxcui 243670
    ASA 81 daily + carvedilol max-tolerated • PO • daily + BID
    trigger: NSTEMI-SCAD long-term
    ESC 2018 SCAD position; observational benefit per Mayo SCAD registry

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Peripartum / postpartum woman (within 12 weeks delivery) with ischemic chest pain + hsTn rise/fall + non-ST-elevation ECG — high SCAD probability; 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.

Objective

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

Assessment

**NSTEMI from spontaneous coronary artery dissection (SCAD)** (cardio.nstemi.scad-related.v1).
Phenotype framing: 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
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)**.
1. 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 (antiplatelet_cox1, first line) — 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)
2. carvedilol 3.125 mg BID titrate to max tolerated (target HR 60–80) PO BID indefinitely (beta_blocker_nonselective_alpha1, first line) — 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
3. metoprolol metoprolol succinate 25–50 mg PO daily titrate (target HR 60–80); preferred in pregnancy / lactation PO daily (beta_blocker_beta1_selective, first line) — Beta1-selective; safer in pregnancy/lactation per ESC 2018 SCAD position; metoprolol succinate or labetalol preferred over carvedilol when pregnancy considerations dominate
4. clopidogrel 300 mg load → 75 mg daily PO daily × duration determined case-by-case (typically 1–12 months if PCI) (p2y12_inhibitor, comorbidity specific) — 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
5. 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 (anticoagulant_indirect, rescue) — AHA 2025 ACS Class I for PCI; in SCAD specifically, AC NOT continued post-procedure to avoid hematoma extension — ESC 2018 SCAD position
6. atorvastatin 40–80 mg daily PO daily (statin_high_intensity, comorbidity specific) — 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)
7. lisinopril 2.5–5 mg daily titrate PO daily (ace_inhibitor, comorbidity specific) — GDMT initiation per ACC/AHA 2022 HF Class I if LVEF reduced post-SCAD-MI; otherwise not routinely needed

Setting playbook (outpatient) — Long-term cardiology surveillance: annual visit, repeat coronary CTA at 1 year then per symptoms, continued BB + ASA, ongoing FMD surveillance, pregnancy counseling, mental-health continuity
8. continue ASA + carvedilol indefinitely ASA 81 daily + carvedilol max-tolerated PO daily + BID — NSTEMI-SCAD long-term (ESC 2018 SCAD position; observational benefit per Mayo SCAD registry)

Non-pharmacologic actions:
- Pregnancy counseling: avoid pregnancy ≥12 mo post-SCAD; if pregnancy desired, multidisciplinary high-risk obstetric + cardiology team mandatory; high recurrence risk in subsequent pregnancy
- Continued FMD surveillance per Hayes 2018 ACC scientific statement
- Patient remains on cardiac rehab maintenance
- Mental-health continuity care

AVOID / contraindication checks:
- Avoid_lytics_absolutely_in_scad_extension_risk (ESC 2018 SCAD position PMID 30033129)
- Avoid_thrombus_aspiration_in_scad_no_atherosclerotic_thrombus_extension_risk (ESC 2018)
- Avoid_dapt_routinely_in_conservative_nstemi_scad_unless_pci_or_thrombus (DISCO trial PMID 33585917; ESC 2018)
- Avoid_anticoagulation_post_procedure_in_scad_extension_risk (ESC 2018)
- Lipid_lowering_only_if_concomitant_ascvd_in_scad (ESC 2018; AHA 2018 SCAD statement PMID 29472380)
- Carvedilol_avoid_severe_bradycardia_or_high_grade_av_block (FDA label)
- Beta_blocker_pregnancy_use_metoprolol_or_labetalol_not_atenolol (ACOG)
- Avoid_pregnancy_12_months_post_scad_high_recurrence_risk (Hayes 2018 ACC SCAD statement)

Monitoring

Regimen monitoring:
- telemetry continuous first 72h extension surveillance (ESC 2018)
- hsTn serial q6h until peak then daily x 2 (4th UDMI)
- echo at admission then weekly x 2 for LV function recovery (Hayes 2018)
- no routine repeat angio at 4 6 weeks unless recurrent symptoms (Mayo SCAD registry — most heal spontaneously)
- fmd screening renal and cerebrovascular CTA or MRA post stabilization (Hayes 2018 PMID 29472380)
- BP q4h inpatient then home log post discharge target SBP <130
- PHQ-9 at every visit post SCAD depression anxiety common (Mayo SCAD registry)

Setting (outpatient) monitoring:
- Annual CTA at 1 yr; thereafter per symptoms
- Annual lipid + BP + BMP
- Annual PHQ-9 + GAD-7

Follow-up plan: 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
- Close-out criterion: FMD screen + contraception + rehab + genetics + mental-health referrals booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term cardiology surveillance: annual visit, repeat coronary CTA at 1 year then per symptoms, continued BB + ASA, ongoing FMD surveillance, pregnancy counseling, mental-health continuity

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists post-SCAD-MI

Escalation triggers (move to higher acuity):
- Recurrent SCAD on CTA → cath + IVUS / OCT
- New connective-tissue / vascular event → genetics + vascular surgery referral
- Pregnancy detected → STAT high-risk obstetric + cardiology consult

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Recurrent chest pain post-conservative-SCAD + repeat angio shows dissection extension or new false lumen
- [LIFE_THREATENING] NSTEMI-SCAD + SBP <90 / shock / large-territory infarct → conservative paradigm overridden, emergent PCI
- [LIFE_THREATENING] Lytic therapy (alteplase, tenecteplase) administered before SCAD diagnosis confirmed — high risk of dissection extension and intramural hematoma propagation

Citations

- 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 [PMID:30033129](https://pubmed.ncbi.nlm.nih.gov/30033129/)
- Cited evidence (PMID 29472380) [PMID:29472380](https://pubmed.ncbi.nlm.nih.gov/29472380/)
- Cited evidence (PMID 22800851) [PMID:22800851](https://pubmed.ncbi.nlm.nih.gov/22800851/)
- Cited evidence (PMID 24574329) [PMID:24574329](https://pubmed.ncbi.nlm.nih.gov/24574329/)
- Cited evidence (PMID 24914054) [PMID:24914054](https://pubmed.ncbi.nlm.nih.gov/24914054/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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 — PMID:30033129
  • Cited evidence (PMID 29472380) — PMID:29472380
  • Cited evidence (PMID 22800851) — PMID:22800851
  • Cited evidence (PMID 24574329) — PMID:24574329
  • Cited evidence (PMID 24914054) — PMID:24914054