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

Treatment of Spontaneous Coronary Artery Dissection (SCAD)

Conservative medical management is the preferred initial approach for clinically stable SCAD patients, with revascularization reserved only for hemodynamic instability or left main/proximal two-vessel dissection with critical flow limitation. 1

Initial Management Strategy

Conservative Management (First-Line for Stable Patients)

For clinically stable patients without high-risk anatomic features, conservative medical therapy is strongly recommended. 2, 1

• Monitor as inpatient for 3-5 days to observe for early complications including dissection extension, vessel occlusion, or hemodynamic deterioration 2, 1
• Conservative management avoids the high procedural failure rate (~50%) and complications associated with PCI in SCAD 3

Indications for Revascularization

Revascularization should be considered only in these specific scenarios:

• Hemodynamic instability or cardiogenic shock 2, 1
• Left main or proximal two-vessel coronary dissection with critical flow limitation 2, 1
• Actively ongoing ischemia despite medical management 2

Choice of revascularization approach:

• PCI for focal, accessible lesions if technically feasible 2, 1
• CABG for left main or multivessel involvement, especially when PCI is technically challenging 2, 1, 3

Critical Pitfall

Avoid routine use of intravascular imaging (OCT/IVUS) unless revascularization has already been decided, as it can worsen the dissection or trigger abrupt vessel closure 3. Use imaging only for diagnostic uncertainty when it will change management 2.

Medical Therapy

Beta-Blockers (Strongly Recommended)

Beta-blockers are strongly recommended as they reduce the risk of recurrent SCAD and should be continued long-term. 1, 4

• This recommendation comes from the European Heart Society and represents the strongest evidence-based pharmacologic intervention 1
• Beta-blockers also provide migraine prophylaxis, which is relevant given the high prevalence of migraine in SCAD patients 4

Antiplatelet Therapy

Aspirin monotherapy is generally safe and beneficial for conservatively managed SCAD patients. 5

• For patients undergoing PCI with stent placement: Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 12 months 3, 5, 6
• For conservatively managed patients: Short-term DAPT (1 month) followed by aspirin monotherapy is reasonable 5
• Avoid potent P2Y12 inhibitors (ticagrelor, prasugrel) in favor of clopidogrel 6

Antihypertensive Therapy

Aggressive blood pressure control is recommended, as hypertension is an independent predictor of recurrent SCAD. 1, 4

Medications to AVOID

The following medications are contraindicated in SCAD:

• Fibrinolytics - can propagate intramural hematoma 5, 6
• Anticoagulants - can worsen hematoma expansion 5, 6
• Glycoprotein IIb/IIIa inhibitors - contraindicated except possibly during PCI with large thrombus burden 3, 5

Other Cardiovascular Medications

• RAAS inhibitors, mineralocorticoid antagonists, and diuretics: Use only if left ventricular ejection fraction is reduced below 50% or heart failure symptoms are present 5, 6
• Statins: Not routinely recommended unless there is left ventricular dysfunction, though they may have pleiotropic benefits 5, 6

Follow-Up and Recurrent Symptoms

Surveillance Strategy

• Repeat coronary angiography at 6-8 weeks if diagnostic uncertainty exists 2
• Coronary CT angiography for follow-up in patients with persistent or recurrent symptoms 1

Management of Recurrent Chest Pain

For new acute coronary syndrome presentation:

• Urgent evaluation with ECG and troponin monitoring 2
• Consider SCAD progression, recurrent SCAD, stenosis, or thrombosis 2

For new or persistent stable angina:

• Evaluate with stress imaging (echo, CMR, or nuclear perfusion) 2
• If high-risk anatomy, consider coronary imaging as initial approach 2

For atypical symptoms:

• Evaluate for non-cardiac causes 2
• Consider healing SCAD, coronary vasospasm, or endothelial dysfunction 2
• Medical management with long-acting nitrates, calcium channel blockers, or ranolazine may be beneficial 2

Comparative Outcomes

Meta-analysis demonstrates no significant difference in mortality, myocardial infarction, or SCAD recurrence between conservative and revascularization approaches. 7

• However, revascularization as first-line treatment is associated with an additional 6.3% risk of target vessel revascularization 7
• This supports the conservative-first strategy for stable patients 7