What is the medical management of spontaneous coronary artery dissection (SCAD)?

Medical Management of Spontaneous Coronary Artery Dissection (SCAD)

Conservative medical therapy is the recommended first-line approach for clinically stable patients with SCAD, while revascularization should be reserved only for patients with ongoing ischemia, hemodynamic instability, or high-risk coronary anatomy. 1, 2

Initial Assessment and Management Algorithm

For Clinically Stable Patients:

• Conservative therapy is recommended 1, 2
• Monitor as inpatient for 3-5 days 1
• Avoid thrombolytic therapy as it can extend dissection and worsen outcomes 2

For Patients with High-Risk Anatomy (Left Main or Proximal 2-Vessel Dissection):

• Consider conservative therapy if clinically stable 1
• Consider CABG in selected cases 1

For Patients with Ongoing Ischemia or Hemodynamic Instability:

• Consider PCI if technically feasible 1, 2
• Consider urgent CABG if PCI is not feasible 1, 2

Pharmacological Management

Antiplatelet Therapy:

• Aspirin for at least 12 months 2, 3, 4
• P2Y12 inhibitor (typically clopidogrel) for 1-12 months in selected patients 2, 3
• Avoid potent P2Y12 inhibitors (ticagrelor, prasugrel) unless PCI performed 3
• For patients who undergo PCI with stenting:
  • DAPT with aspirin and clopidogrel for 12 months 3, 4

Anti-Hypertensive Therapy:

• Beta-blockers are strongly recommended as they have been associated with reduced risk of recurrent SCAD 1, 2, 3, 4
• Aggressive blood pressure control is important as hypertension is an independent predictor of recurrent SCAD 1

Other Medications:

• For post-SCAD chest pain without obstructive disease:
  • Long-acting nitrates
  • Calcium channel blockers
  • Ranolazine 1
• For patients with heart failure (LVEF <50%):
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Mineralocorticoid antagonists
  • Loop diuretics 3
• Statins may be considered for pleiotropic properties, though evidence is limited 2, 3

Important Contraindications

• Avoid fibrinolytic agents as they may worsen dissection 3, 4
• Avoid anticoagulants as they may promote hematoma propagation 3, 4
• Avoid glycoprotein IIb/IIIa inhibitors 4
• Avoid hormonal therapy in patients who develop SCAD during pregnancy 4

Follow-up Management

• Screening for fibromuscular dysplasia (FMD) in other vascular beds is recommended (present in up to 72% of SCAD cases) 2
• For patients with recurrent chest pain after SCAD:
  • Evaluate with stress imaging (echocardiography, cardiac MRI, nuclear perfusion) 1
  • Consider coronary imaging for high-risk anatomy or compelling clinical scenarios 1

Revascularization Considerations

• PCI in SCAD carries significant risks:
  • High failure rate
  • Risk of extending dissection
  • Risk of iatrogenic dissection 2
• If PCI is necessary, use intracoronary imaging (OCT/IVUS) to confirm true lumen placement 2, 5
• Consider specialized PCI techniques when necessary:
  • Long stents to seal entire dissection length
  • Stepwise stenting (distal to proximal)
  • Bioabsorbable stents in selected cases 5

Common Pitfalls to Avoid

1. Misdiagnosing SCAD as atherosclerotic disease
2. Premature intervention in stable patients with preserved coronary flow
3. Using thrombolytics which can worsen outcomes
4. Failing to screen for associated conditions like fibromuscular dysplasia
5. Not recognizing that SCAD has a high rate of spontaneous healing with conservative management

By following this structured approach to SCAD management, clinicians can optimize outcomes while minimizing unnecessary interventions that may worsen the condition.