What is the treatment for coronary artery dissection?

Treatment of Coronary Artery Dissection

For spontaneous coronary artery dissection (SCAD), a conservative medical approach should be the first-line treatment strategy in hemodynamically stable patients without ongoing ischemia, regardless of angiographic appearance. 1

Diagnostic Approach

• SCAD predominantly affects women (>90% of cases) 1
• Common triggers include emotional/physical stress 1
• Associated with fibromuscular dysplasia in up to 72% of cases 1
• Presents most commonly as acute coronary syndrome with elevated cardiac biomarkers 1

Treatment Algorithm

Initial Assessment

1. Determine hemodynamic stability and presence of ongoing ischemia
2. Assess coronary anatomy via angiography
   • Note: Intravascular imaging (IVUS/OCT) should only be considered if revascularization is already planned, as it may worsen dissection 1

Treatment Strategy Based on Clinical Presentation

Conservative Management (Preferred for most patients)

• Indicated for:

  • Hemodynamically stable patients
  • No ongoing ischemia
  • Preserved coronary flow (TIMI 2-3)

• Medical therapy:

  • Antiplatelet therapy:
    • Aspirin for at least 12 months 1
    • P2Y12 inhibitor (typically clopidogrel) for 1-12 months 1
  • Beta-blockers: Should be considered as they reduce risk of recurrent SCAD 1
  • Aggressive anti-hypertensive therapy: Important as hypertension is an independent predictor of recurrent SCAD 1

Revascularization (Reserved for high-risk patients)

• Indications for intervention:

  • Ongoing ischemia involving major coronary territory
  • Hemodynamic instability
  • Left main involvement
  • Recurrent ACS episodes despite maximal medical therapy 1

• Revascularization options:

  • PCI: Challenging with ~50% failure rate 1
  • CABG: Consider for left main involvement or failed PCI 1

Important Considerations and Pitfalls

PCI Challenges

• High failure rate (~50%) even in patients with normal coronary flow at baseline 1
• 13% of PCI attempts may require emergency CABG due to complications 1
• Risks include:
  • Extension of dissection
  • Propagation of intramural hematoma
  • Abrupt vessel closure during intervention

Long-term Management

• Monitor for recurrence (occurs in 10-30% of cases)
• Aggressive blood pressure control
• Beta-blocker therapy should be maintained long-term 1
• Screen for associated conditions (fibromuscular dysplasia, connective tissue disorders)

Special Considerations

• In patients who receive stents for SCAD, dual antiplatelet therapy with aspirin and ticagrelor (or prasugrel) for one year followed by aspirin alone is reasonable 1
• When switching from clopidogrel to ticagrelor, administer a loading dose of 180 mg ticagrelor 1

The management of SCAD differs significantly from atherosclerotic coronary disease, with a greater emphasis on conservative therapy due to the high rate of spontaneous healing and the significant technical challenges and complications associated with revascularization attempts.