What are the treatment options for coronary artery dissection?

Treatment Options for Coronary Artery Dissection

The treatment of coronary artery dissection should follow a conservative approach when possible, with revascularization reserved for cases with ongoing ischemia involving a major coronary territory or recurrent acute coronary syndrome episodes despite maximal medical therapy. 1

Treatment Algorithm Based on Clinical Presentation

Conservative Management

• Preferred first-line approach for spontaneous coronary artery dissection (SCAD) without ongoing ischemia, regardless of angiographic appearance 1
• Indicated when coronary flow is normal and patient is hemodynamically stable 1
• Conservative management is associated with better outcomes than percutaneous coronary intervention (PCI) in stable SCAD cases, as PCI has approximately 50% failure rate in these patients 1, 2

Medical Therapy

• Antiplatelet therapy:
  • For conservatively managed SCAD: Aspirin for at least 12 months plus clopidogrel for 1-12 months 1, 2
  • For SCAD treated with drug-eluting stent (DES): Aspirin plus ticagrelor or prasugrel for one year, followed by aspirin alone 1
  • When switching from clopidogrel to ticagrelor, a loading dose of 180 mg ticagrelor should be administered 1
• Beta-blockers are strongly recommended as they reduce risk of recurrent SCAD while also providing additional benefits 3, 2
• Avoid fibrinolytics, anticoagulants, and glycoprotein IIa/IIIb inhibitors as they are contraindicated in SCAD 2
• Statins and RAAS inhibitors are not recommended unless there is left ventricular dysfunction 2

Invasive Management

• Revascularization indications:

  • Ongoing ischemia involving a major coronary territory 1
  • Recurrent acute coronary syndrome episodes despite maximal medical treatment 1
  • Left main trunk involvement (consider CABG in these cases) 1, 4
  • Hemodynamic instability 2, 4

• PCI considerations:

  • Should be performed by experienced operators 4
  • Intravascular imaging (IVUS or OCT) helps confirm diagnosis and document disease extension, but should only be used if revascularization decision is already made 1, 2
  • Stenting is the most common interventional approach (used in 73% of iatrogenic dissection cases) 5
  • Cutting balloon angioplasty may be considered in select cases to create communication between true and false lumens 6

• CABG considerations:

  • Reserved for left main involvement or failed PCI 1, 4
  • Emergency CABG may be required in approximately 2% of iatrogenic dissection cases 5

Special Considerations

Iatrogenic vs. Spontaneous Dissection

• Iatrogenic dissections during PCI:

  • Most commonly caused by guidewire advancement (30%), stenting (22%), balloon angioplasty (20%), and guide-catheter engagement (18%) 5
  • Associated with significant adverse outcomes: 9% acute MI rate and 7% in-hospital mortality 5
  • Stenting is the preferred treatment (used in 73% of cases) 5

• Spontaneous coronary artery dissection (SCAD):

  • Affects women in over 90% of cases 1, 3
  • Often precipitated by emotional or physical stress 1, 3
  • Associated with fibromuscular dysplasia in up to 72% of cases 1, 3
  • Conservative management preferred when possible 2, 4

Pitfalls and Caveats

• PCI for SCAD has high failure rates (approximately 50%), even in cases with normal coronary flow at baseline 1
• Intravascular imaging can trigger abrupt vessel closure if used inappropriately 1
• Dissections starting at the ostium with difficult true lumen identification carry higher risk for abrupt occlusion during PCI 1
• Hormonal therapy is contraindicated for patients who develop SCAD during pregnancy 2
• Future pregnancy is discouraged in women with history of SCAD 2

Follow-up Care

• Close monitoring is essential as both SCAD and complications can recur 3
• Stress management techniques are recommended as SCAD is often precipitated by stress 3
• Regular cardiovascular follow-up with imaging to assess healing 2, 4