What is the treatment for Spontaneous Coronary Artery Dissection (SCAD)?

Treatment of Spontaneous Coronary Artery Dissection (SCAD)

For patients with Spontaneous Coronary Artery Dissection (SCAD), a conservative medical approach should be the first-line treatment strategy, with revascularization reserved only for patients with ongoing ischemia, hemodynamic instability, or high-risk coronary anatomy. 1

Initial Management Approach

Conservative Management (First-Line)

• Indicated for: Clinically stable patients with preserved coronary flow (TIMI flow 3)
• Duration: Monitor as inpatient for 3-5 days to ensure stability 1, 2
• Pharmacological therapy:
  • Beta-blockers: Strongly recommended as they are significantly associated with reduced risk of recurrent SCAD 1, 2, 3
  • Antihypertensive therapy: Aggressive blood pressure control is essential as hypertension is an independent predictor of recurrent SCAD 1, 2
  • Antiplatelet therapy:
    • Aspirin for at least 12 months 2, 4
    • Consider single antiplatelet therapy rather than dual antiplatelet therapy (DAPT) in conservatively managed patients 3, 4
    • If DAPT is used, prefer clopidogrel over more potent P2Y12 inhibitors (ticagrelor, prasugrel) 3

Revascularization (Reserved for Specific Scenarios)

• Indications for intervention:

  1. Ongoing ischemia despite maximal medical therapy
  2. Hemodynamic instability
  3. High-risk coronary anatomy (left main or proximal two-vessel dissection)
  4. Major arrhythmias (ventricular tachycardia, ventricular fibrillation)
  5. Compromised coronary flow (TIMI flow 0-2) 1, 2

• Revascularization options:

  • PCI: Consider for accessible lesions, but high risk of complications
  • CABG: Consider for left main or proximal multivessel dissection 1

Management Algorithm

1. Diagnosis confirmation:

   • Coronary angiography with intracoronary nitrates
   • If diagnostic uncertainty: Consider OCT/IVUS if feasible/safe 1, 2

2. Risk stratification:

   • Low-risk: Stable, preserved coronary flow, distal vessel involvement
   • High-risk: Ongoing ischemia, hemodynamic instability, left main/proximal vessel involvement

3. Treatment decision:

   • If low-risk: Conservative therapy with medical management
   • If high-risk: Consider revascularization based on technical considerations and local expertise

Special Considerations

PCI Technical Challenges

• High failure rate (up to 53%)
• Risk of extending dissection
• Risk of iatrogenic dissection
• Use intravascular imaging to confirm true lumen 2

Post-SCAD Management

• For recurrent chest pain after SCAD:
  • Evaluate with stress imaging (echocardiography, cardiac MRI, nuclear perfusion)
  • Consider coronary imaging for high-risk anatomy 1, 2

Medications to Avoid

• Fibrinolytic agents
• Anticoagulants
• Glycoprotein IIb/IIIa inhibitors
• These may worsen dissection or promote hematoma propagation 2, 3, 4

Long-term Follow-up

• Screen for fibromuscular dysplasia (FMD) in other vascular beds (present in up to 72% of SCAD cases) 2
• Consider long-term beta-blocker therapy to prevent recurrence 1, 3
• Annual clinical follow-up recommended 5

Future Directions

The ongoing BA-SCAD randomized clinical trial will provide more definitive evidence regarding the efficacy of beta-blockers and optimal duration of antiplatelet therapy in SCAD patients 5.