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cardio.stemi.scad.v1PRODUCTION
cardio.stemi.scad.v1

STEMI from spontaneous coronary artery dissection (SCAD)

cardiologyacuteadultpregnancy
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10/12 authored

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

Current phase

Frame

Detailed

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.

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SCAD probability stratified

Patient inputs (11)

SCAD skews younger (mean ~44 years) than atherosclerotic ACS; >90% are women

Peripartum / postpartum women are the highest-incidence SCAD subgroup; pregnancy status drives both diagnosis probability and treatment choices (DAPT contraindications)

FMD coexists in 20-50% of SCAD; presence raises pre-test probability and changes long-term surveillance (renal + cerebrovascular FMD screening)

eGFR for contrast + DOAC dosing if PCI performed

ST elevation pattern + territory; SCAD often presents with NSTEMI but STEMI possible with full-thickness occlusion

Quantifies infarct burden; higher troponin + larger territory → tip toward PCI vs conservative

LVEF + regional wall motion; serial echo for thrombus / aneurysm if conservative management

Hemodynamic stability drives the conservative-vs-PCI decision; SBP <90 + ongoing ischemia → PCI despite extension risk

Diagnostic gold standard combined with intracoronary imaging; Yip-Saw classification determines SCAD subtype + management

Ehlers-Danlos vascular type, Marfan, Loeys-Dietz raise SCAD probability and change long-term genetics referral

Intravascular imaging (IVUS or OCT) confirms intramural hematoma + false lumen — gold standard when angiogram is ambiguous; OCT preferred for resolution

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

Severity triggers (4)

4 need judgement
  • informationallife_threateningscad_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_threateningscad_with_hemodynamic_instability_requiring_pci
    SCAD-STEMI + SBP <90 / shock / large-territory infarct → conservative paradigm overridden, emergent PCI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverescad_recurrence_in_first_year
    New chest pain + ECG / troponin changes within 12 months of index SCAD — recurrence rate ~10-30% in observational series
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverescad_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.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

SCAD conservative-first regimen — overrides parent cardio.stemi.core.v1 DAPT default; uses single antiplatelet + BB; PCI/AC reserved for instability
axis: scad_conservative_first_phenotype
Selected axis "SCAD conservative-first regimen — overrides parent cardio.stemi.core.v1 DAPT default; uses single antiplatelet + BB; PCI/AC reserved for instability" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    81 mg daily (no load if conservative) OR 162-325 mg load if PCI • PO • daily indefinitely if no PCI; daily × 12 mo per ACS protocol if PCI
    triggers: scad_confirmed
    ESC 2018 SCAD position (PMID 30033129) — single antiplatelet sufficient for most; ASA continued indefinitely per Mayo SCAD registry consensus
    rxcui 243670
  • carvedilol
    first line
    beta_blocker_nonselective
    3.125 mg BID titrate to max tolerated • PO • BID indefinitely
    triggers: scad_confirmed
    ESC 2018 SCAD position (PMID 30033129) — BB reduce wall stress + may reduce recurrence; observational data only
    rxcui 20352
  • clopidogrel
    comorbidity specific
    p2y12_inhibitor
    300 mg load → 75 mg daily • PO • daily × duration determined case-by-case
    triggers: scad_with_pci_performed, scad_with_intraluminal_thrombus_on_imaging
    Add P2Y12 only if PCI performed (mandatory DAPT post-stent) OR intracoronary thrombus on imaging; clopidogrel preferred over ticagrelor in SCAD due to lower bleeding extension risk
    rxcui 309362
  • unfractionated heparin
    rescue
    anticoagulant_indirect
    70-100 U/kg IV bolus, NOT continued post-cath in conservative SCAD • IV • bolus only at PCI; discontinue post-procedure
    triggers: scad_with_pci_performed
    AHA 2025 ACS Class I for PCI; in SCAD specifically, AC NOT continued post-procedure to avoid hematoma extension
    rxcui 5224
  • atorvastatin
    comorbidity specific
    statin_high_intensity
    40-80 mg daily • PO • daily
    triggers: scad_with_concomitant_ascvd, 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 STEMI default
    rxcui 83367
  • lisinopril
    comorbidity specific
    ace_inhibitor
    2.5-5 mg daily titrate • PO • daily
    triggers: scad_with_lv_dysfunction_ef_below_40, 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 5487

outpatient playbook — drug actions (1)

  1. 1. continue ASA + carvedilol indefinitely
    rxcui 243670
    ASA 81 daily + carvedilol max-tolerated • PO • daily + BID
    trigger: 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 with ischemic chest pain + ST elevation — high SCAD probability; 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; Patient with known FMD, Ehlers-Danlos, Marfan, or Loeys-Dietz presenting with STEMI — pre-test probability of SCAD high.

Objective

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

Assessment

**STEMI from spontaneous coronary artery dissection (SCAD)** (cardio.stemi.scad.v1).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **SCAD conservative-first regimen — overrides parent cardio.stemi.core.v1 DAPT default; uses single antiplatelet + BB; PCI/AC reserved for instability**.
1. aspirin 81 mg daily (no load if conservative) OR 162-325 mg load if PCI PO daily indefinitely if no PCI; daily × 12 mo per ACS protocol if PCI (antiplatelet_cox1, first line) — ESC 2018 SCAD position (PMID 30033129) — single antiplatelet sufficient for most; ASA continued indefinitely per Mayo SCAD registry consensus
2. carvedilol 3.125 mg BID titrate to max tolerated PO BID indefinitely (beta_blocker_nonselective, first line) — ESC 2018 SCAD position (PMID 30033129) — BB reduce wall stress + may reduce recurrence; observational data only
3. clopidogrel 300 mg load → 75 mg daily PO daily × duration determined case-by-case (p2y12_inhibitor, comorbidity specific) — Add P2Y12 only if PCI performed (mandatory DAPT post-stent) OR intracoronary thrombus on imaging; clopidogrel preferred over ticagrelor in SCAD due to lower bleeding extension risk
4. unfractionated heparin 70-100 U/kg IV bolus, 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
5. 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 STEMI default
6. 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
7. continue ASA + carvedilol indefinitely ASA 81 daily + carvedilol max-tolerated PO daily + BID — 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

AVOID / contraindication checks:
- Avoid_dapt_routinely_in_scad_unless_pci_or_thrombus (ESC 2018 SCAD position)
- Avoid_anticoagulation_post_procedure_in_scad (extension risk)
- Lipid_lowering_only_if_concomitant_ascvd_in_scad
- Carvedilol_avoid_severe_bradycardia_or_high_grade_av_block

Monitoring

Regimen monitoring:
- telemetry continuous first 72h extension surveillance
- echo at admission then weekly x 2 for LV function recovery
- no routine repeat angio at 4 6 weeks unless recurrent symptoms (most heal spontaneously)
- fmd screening renal and cerebrovascular CTA or MRA post stabilization

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

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

Monitoring phase: 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

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

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] SCAD-STEMI + SBP <90 / shock / large-territory infarct → conservative paradigm overridden, emergent PCI
- [SEVERE] New chest pain + ECG / troponin changes within 12 months of index SCAD — recurrence rate ~10-30% in observational series

Citations

- ESC 2018 SCAD position paper + Hayes 2018 ACC SCAD scientific statement + 2025 ACC/AHA ACS Guideline + Mayo Clinic SCAD registry [PMID:24574329](https://pubmed.ncbi.nlm.nih.gov/24574329/)
- Cited evidence (PMID 30033129) [PMID:30033129](https://pubmed.ncbi.nlm.nih.gov/30033129/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ESC 2018 SCAD position paper + Hayes 2018 ACC SCAD scientific statement + 2025 ACC/AHA ACS Guideline + Mayo Clinic SCAD registry — PMID:24574329
  • Cited evidence (PMID 30033129) — PMID:30033129
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 38587234) — PMID:38587234