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

Treatment of Spontaneous Coronary Artery Dissection (SCAD)

Conservative medical management with beta-blockers and aggressive blood pressure control is the preferred initial treatment for clinically stable SCAD patients, reserving revascularization only for hemodynamically unstable patients or those with left main/proximal two-vessel dissection. 1, 2

Acute Management Strategy

Initial Approach for Stable Patients

• Conservative medical therapy is the cornerstone of SCAD management for clinically stable patients without high-risk features 1, 2
• Admit all SCAD patients for inpatient monitoring for 3-5 days to observe for early complications including dissection extension, recurrent ischemia, or hemodynamic deterioration 1, 2
• This conservative approach is supported by meta-analysis data showing no mortality or myocardial infarction benefit with revascularization, but an additional 6.3% risk of target vessel revascularization when intervention is used as first-line therapy 3

Indications for Revascularization

Revascularization (PCI or CABG) should be reserved for specific high-risk scenarios only 1, 2:

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

A critical pitfall is attempting PCI in stable patients, as revascularization carries higher complication rates in SCAD due to the fragile dissected vessel wall 4, 3

Medical Therapy

Beta-Blockers (First-Line)

• Beta-blockers are the most important medication for SCAD and should be initiated in all patients unless contraindicated 1, 2
• Beta-blockers reduce the risk of recurrent SCAD and should be continued indefinitely for recurrence prevention 1, 2, 5
• This recommendation is based on their ability to reduce arterial wall stress and prevent dissection propagation 5

Blood Pressure Control (Essential)

• Aggressive anti-hypertensive therapy is essential, as hypertension is an independent predictor of recurrent SCAD 1, 2, 5
• Use ACE inhibitors, ARBs, or non-dihydropyridine calcium channel blockers to achieve normal blood pressure 1, 5
• Target aggressive blood pressure control to reduce arterial wall stress 5

Antiplatelet Therapy

• Aspirin is generally safe and beneficial for SCAD patients 6
• For conservatively managed patients (no PCI), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel may be given for a short period (1 month) followed by single antiplatelet therapy with aspirin 6
• If stenting was performed, continue DAPT for 12 months 7
• Avoid potent P2Y12 inhibitors (ticagrelor, prasugrel) as they may increase bleeding risk without proven benefit 7

Medications to AVOID

• Fibrinolytic agents are contraindicated as they could favor hematoma propagation 7, 6
• Anticoagulants should be avoided for the same reason 7, 6
• Glycoprotein IIb/IIIa inhibitors are contraindicated 6
• Exogenous hormones should be avoided in all SCAD patients, including those with pregnancy-associated SCAD 1

Additional Medications

• Statins may be used due to their pleiotropic properties, though evidence is limited 7
• RAAS inhibitors and mineralocorticoid antagonists are recommended only if left ventricular ejection fraction is below 50% or heart failure symptoms are present 7, 6

Screening for Associated Conditions

Fibromuscular Dysplasia (FMD)

• Systematic screening for FMD is recommended in all SCAD patients, as FMD is present in up to 72% of SCAD cases 1, 5
• Vascular imaging from brain to pelvis should be considered in all SCAD patients 1
• Annual non-invasive imaging of carotid arteries is reasonable initially, with less frequent studies once stability is confirmed 5
• Platelet inhibitor medication is beneficial for FMD of the carotid arteries to prevent thromboembolism 5
• Revascularization is NOT recommended for asymptomatic FMD of a carotid artery, regardless of stenosis severity 5

Management of Recurrent Symptoms

Acute Presentation

• Evaluate urgent presentations per standard ACS guidelines with ECG, troponin monitoring, and imaging 1
• Consider coronary imaging as initial approach if high-risk anatomy or compelling clinical scenario 1

Stable Angina

• Evaluate with stress imaging first 1
• Coronary CT angiography may be used for follow-up imaging in patients with persistent or recurrent symptoms 1, 2

Long-Term Management

• Continue beta-blocker therapy indefinitely for recurrence prevention 1, 2, 5
• Implement stress management techniques, as SCAD is often precipitated by emotional or physical stress 1, 5
• Perform regular follow-up on an ongoing basis 4
• The prognosis is generally good with low long-term mortality when managed appropriately 4