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

Treatment of Spontaneous Coronary Artery Dissection (SCAD)

Conservative management is the first-line treatment for clinically stable SCAD patients, while revascularization should be reserved only for cases with ongoing ischemia, hemodynamic instability, or left main/proximal two-vessel involvement with critical flow limitation. 1, 2

Initial Management Approach

• Treatment strategy depends on clinical presentation, hemodynamic status, and coronary anatomy 1
• For clinically stable patients without high-risk features:
  • Conservative medical therapy is recommended 1, 2
  • Inpatient monitoring for 3-5 days to observe for early complications 1, 2
• Revascularization (PCI or CABG) should be considered only in:
  • Patients with actively ongoing ischemia 1
  • Hemodynamic instability 1
  • Left main or proximal two-vessel coronary dissection with critical flow limitation 1, 2

Medical Therapy

• Beta-blockers:
  • Strongly recommended as they have been associated with reduced risk of recurrent SCAD 2, 3
  • Should be continued long-term for prevention of recurrence 2, 4
• Antiplatelet therapy:
  • Single antiplatelet therapy (SAPT) with aspirin is appropriate for conservatively managed patients without high-risk angiographic features 3, 5
  • Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel should be used if PCI was performed, continuing for 12 months 3, 4
  • Potent P2Y12 inhibitors (ticagrelor, prasugrel) should be avoided in SCAD patients 3
  • Recent evidence suggests SAPT may be associated with better outcomes than DAPT in conservatively managed patients (6% vs 18.9% MACE rate) 5
• Blood pressure management:
  • Aggressive anti-hypertensive therapy is recommended as hypertension is an independent predictor of recurrent SCAD 2

Medications to Avoid

• Fibrinolytic agents and anticoagulants should be avoided as they could worsen the intramural hematoma 3, 4
• Glycoprotein IIb/IIIa inhibitors are contraindicated 4
• Potent P2Y12 inhibitors (ticagrelor, prasugrel) should be avoided when possible 3

Revascularization Considerations

• PCI in SCAD has high failure rates (approximately 50%) and may worsen the dissection 1
• If revascularization is necessary:
  • PCI for focal, accessible lesions with ongoing ischemia 1
  • CABG for left main or multivessel involvement, especially when PCI is technically challenging 1, 2
• Intravascular imaging (OCT/IVUS) should only be used if revascularization decision has already been made, as it may trigger vessel closure 1

Long-term Management and Follow-up

• Long-term beta-blocker therapy should be continued to prevent recurrence 2, 3
• For patients with preserved left ventricular function, the optimal duration of beta-blocker therapy is being investigated in ongoing trials 6
• Consider coronary CT angiography for follow-up in patients with persistent or recurrent symptoms 2
• Evaluate for associated conditions, particularly fibromuscular dysplasia which occurs in up to 72% of SCAD cases 7

Management of Post-SCAD Chest Pain

• New acute ACS: Urgent evaluation following acute chest pain guidelines 1
• New or persistent stable angina: Evaluate with stress imaging (echo, CMR, nuclear perfusion) 1
• Atypical symptoms: Consider non-cardiac causes, address symptom triggers, and evaluate for coronary vasospasm or endothelial dysfunction 1