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

Treatment Options for Spontaneous Coronary Artery Dissection (SCAD)

For patients with Spontaneous Coronary Artery Dissection (SCAD), a conservative medical approach should be the preferred treatment strategy in hemodynamically stable patients without high-risk features, as this approach is associated with better outcomes than percutaneous coronary intervention (PCI). 1, 2, 3

Initial Management Approach

• Conservative medical therapy is recommended for clinically stable patients without high-risk features 1, 2
• Inpatient monitoring for 3-5 days is recommended to observe for early complications 2
• Revascularization (PCI or CABG) should be reserved only for:
  • Hemodynamically unstable patients 2
  • Left main or proximal two-vessel coronary dissection with critical flow limitation 2, 3
  • Ongoing ischemia despite medical therapy 1

Medical Therapy Options

• Beta-blockers are strongly recommended as first-line therapy as they have been associated with a reduced risk of recurrent SCAD 1, 2, 4
• Aggressive anti-hypertensive therapy is recommended as hypertension is an independent predictor of recurrent SCAD 1, 4
• Antiplatelet therapy recommendations:
  • For conservatively managed SCAD: Aspirin for at least 12 months plus clopidogrel for 1-12 months 3, 5
  • For SCAD treated with drug-eluting stent: Aspirin plus ticagrelor or prasugrel for one year, followed by aspirin alone 3
  • Potent P2Y12 inhibitors (ticagrelor, prasugrel) should be avoided in conservatively managed cases 5
• Fibrinolytic agents and anticoagulants should be avoided as they may promote hematoma propagation 5

Revascularization Considerations

• PCI has approximately 50% failure rate in SCAD cases, even with normal coronary flow at baseline 3, 6
• If revascularization is necessary, consider:
  • PCI for focal, accessible lesions with ongoing ischemia 2
  • CABG for left main or multivessel involvement, especially when PCI is technically challenging 2, 6
• Intravascular imaging (OCT or IVUS) should be used judiciously as it can potentially worsen the dissection 3, 6

Diagnostic Confirmation

• Diagnosis is typically confirmed by coronary angiography 2
• 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, 2

Long-term Management

• Long-term beta-blocker therapy should be continued to prevent recurrence 2, 4
• Consider coronary CT angiography (CCTA) for follow-up in patients with persistent or recurrent symptoms 1, 2
• Heart failure medications (ACE inhibitors, ARBs, mineralocorticoid antagonists) should be used in patients with reduced left ventricular ejection fraction below 50% 5

Special Considerations

• SCAD is more common in women (90.5%), particularly those under 60 years of age 1, 2
• Fibromuscular dysplasia is present in up to 72% of SCAD cases 3, 4
• Emotional or physical stressors often precipitate SCAD events 3, 4
• A randomized clinical trial (BA-SCAD) is currently evaluating the efficacy of beta-blockers and antiplatelet therapy duration in SCAD patients 7

Common Pitfalls and Caveats

• Avoid aggressive coronary interventions in stable patients as they may worsen the dissection 3, 6
• Dissections starting at the ostium with difficult true lumen identification carry higher risk for abrupt occlusion during PCI 3, 6
• Recurrent SCAD occurs in approximately 10.4% of patients, with hypertension increasing risk and beta-blocker therapy appearing protective 4
• The overall major adverse cardiac event rate during long-term follow-up (median 3.1 years) is approximately 19.9% 4