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

Treatment of Spontaneous Coronary Artery Dissection (SCAD)

A conservative medical approach should be the preferred first-line treatment strategy for most patients with SCAD, with revascularization reserved only for high-risk cases with ongoing ischemia, hemodynamic instability, or involvement of critical coronary segments. 1

Diagnosis Confirmation

• SCAD is defined as a non-atherosclerotic, non-traumatic separation of coronary arterial layers creating a false lumen and downstream myocardial ischemia 1
• Diagnosis is typically confirmed by coronary angiography, with three angiographic types:
  • Type 1: Contrast dye staining with multiple radiolucent lumens
  • Type 2: Long diffuse and smooth narrowing
  • Type 3: Focal stenosis mimicking atherosclerosis 1
• In unclear cases, intracoronary imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is recommended to confirm the presence of intramural hematoma or double lumen 1

Initial Management Approach

• For clinically stable patients without high-risk features, conservative medical therapy is recommended 1, 2
• Monitor stable patients as inpatients for 3-5 days to observe for early complications 1
• Revascularization (PCI or CABG) should be considered only in the following scenarios:
  • Ongoing ischemia despite medical therapy
  • Hemodynamic instability
  • Left main or proximal two-vessel coronary dissection with critical flow limitation 1

Medical Therapy

• Beta-blockers are strongly recommended as they have been associated with reduced risk of recurrent SCAD 1, 3, 4
• Aggressive anti-hypertensive therapy is recommended as hypertension is an independent predictor of recurrent SCAD 1, 3
• Antiplatelet therapy:
  • For conservatively managed patients, aspirin alone may be sufficient 4, 5
  • For patients undergoing PCI, dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended 4, 5
  • Potent P2Y12 inhibitors (ticagrelor, prasugrel) should be avoided 4
• Contraindicated medications:
  • Fibrinolytic agents
  • Anticoagulants
  • Glycoprotein IIb/IIIa inhibitors 4, 5

Revascularization Considerations

• PCI in SCAD is associated with higher technical failure rates and complications compared to atherosclerotic disease 2
• If revascularization is necessary, consider:
  • PCI for focal, accessible lesions with ongoing ischemia
  • CABG for left main or multivessel involvement, especially when PCI is technically challenging 1
• Revascularization as first-line treatment is associated with an increased risk of target vessel revascularization (additional risk of 6.3%) 2

Long-term Management and Follow-up

• Long-term beta-blocker therapy should be continued to prevent recurrence 1, 3, 4
• For patients with reduced left ventricular ejection fraction (<50%), add:
  • ACE inhibitors or ARBs
  • Mineralocorticoid antagonists
  • Loop diuretics as needed 4, 5
• Consider coronary CT angiography (CCTA) for follow-up in patients with persistent or recurrent symptoms 1
• Evaluate for associated conditions, particularly fibromuscular dysplasia, which is present in up to 62.7% of SCAD patients 3

Prognosis and Recurrence

• Long-term major adverse cardiac events occur in approximately 19.9% of patients 3
• Recurrent SCAD occurs in about 10.4% of patients 3
• Risk factors for recurrence include:
  • Hypertension (increases risk by 2.46 times)
  • Not using beta-blockers (beta-blockers reduce risk by 64%) 3

Special Considerations

• SCAD is more common in women (90.5%), particularly those under 60 years of age 1, 3
• Pregnancy-associated SCAD requires specialized management; future pregnancies are generally discouraged 5
• Emotional and physical stressors are common precipitants and should be addressed 3