What is the treatment for a patient with a small possibility of spontaneous coronary artery dissection?

Treatment of Suspected Spontaneous Coronary Artery Dissection

For patients with suspected SCAD who are clinically stable, conservative medical management is the preferred initial approach, as it achieves better outcomes than percutaneous coronary intervention and avoids the approximately 50% failure rate associated with PCI in stable SCAD cases. 1

Initial Diagnostic Confirmation

When SCAD is suspected but not definitively confirmed on angiography:

• Perform intracoronary imaging (OCT or IVUS) only if you have already decided to proceed with revascularization, as these modalities can trigger abrupt vessel closure 2
• Consider CT coronary angiography, especially for proximal lesions, as a safer alternative for diagnostic confirmation 3
• If diagnostic uncertainty persists and the patient is stable, repeat coronary angiography at 6-8 weeks rather than risking complications with immediate invasive imaging 3

Treatment Algorithm Based on Clinical Stability

Clinically Stable Patients (Preferred Scenario)

Conservative medical management is indicated regardless of angiographic appearance when coronary flow is normal and hemodynamics are stable 1:

• Admit for inpatient monitoring for 3-5 days 3
• Initiate dual antiplatelet therapy: aspirin for at least 12 months PLUS clopidogrel for 1-12 months 1
• Add beta-blockers, which reduce recurrent SCAD risk 4
• Implement aggressive blood pressure control, as hypertension independently predicts recurrent SCAD 4

The European Society of Cardiology specifically recommends this conservative approach because PCI has approximately 50% failure rates even in cases with normal coronary flow at baseline 1, 2.

Actively Ongoing Ischemia or Hemodynamic Instability

Consider PCI if technically feasible OR urgent CABG based on local expertise and technical considerations 3:

• Recognize that dissections starting at the ostium with difficult true lumen identification carry higher risk for abrupt occlusion during PCI 1, 2
• If PCI is performed and a drug-eluting stent is placed, switch to aspirin plus ticagrelor or prasugrel for one year (use 180 mg loading dose when switching from clopidogrel to ticagrelor), followed by aspirin alone 1

High-Risk Anatomy (Left Main or Severe Proximal 2-Vessel Dissection)

Consider CABG for left main or severe proximal 2-vessel dissection, though conservative management may be reasonable in stable patients 3:

• This scenario remains understudied, so clinical judgment is paramount 3
• Emergency CABG should be considered if PCI is not feasible or fails 2

Critical Pitfalls to Avoid

• Never use fibrinolytics, anticoagulants, or glycoprotein IIb/IIIa inhibitors in suspected or confirmed SCAD, as these are contraindicated and can worsen outcomes 5
• Avoid routine use of intravascular imaging for diagnosis alone, as it can precipitate vessel closure 1, 2
• Do not default to PCI simply because it is available—the 50% failure rate in stable SCAD makes conservative management superior 1

Special Population Considerations

SCAD affects women in over 90% of cases and is associated with fibromuscular dysplasia in up to 72% of patients 1, 4:

• Screen for extracoronary vascular abnormalities and fibromuscular dysplasia using CT/MRA angiographic imaging 3
• Address emotional and physical stress triggers, as SCAD is often precipitated by stress 1, 4
• Implement stress management techniques as part of long-term care 1, 4

Follow-Up Strategy

Close monitoring is essential as both SCAD and its complications can recur 1:

• For conservatively managed patients, consider repeat coronary angiography at 6-8 weeks if symptoms persist or diagnostic uncertainty remains 3
• For patients who received PCI with left main involvement, consider follow-up angiography between 2-6 months 2
• Monitor for signs of restenosis requiring repeat intervention 2