Management of SCAD in a 61-Year-Old Male
Conservative medical management with beta-blockers and aggressive blood pressure control is the recommended initial approach for this clinically stable 61-year-old male with SCAD, reserving revascularization only for hemodynamic instability or high-risk anatomical features. 1, 2
Initial Assessment and Monitoring
Admit for inpatient observation for 3-5 days to monitor for early complications including dissection extension, recurrent ischemia, or hemodynamic deterioration. 1, 2, 3
During this period, perform:
- Serial troponin measurements using high-sensitivity assays to rule out ongoing myocardial necrosis 4
- Continuous ECG monitoring for arrhythmias 4
- Resting echocardiography to assess left ventricular function, regional wall motion abnormalities, and exclude alternative diagnoses 4
- Full blood count, renal function (creatinine clearance), fasting glucose, and HbA1c 4
Diagnostic Confirmation
While diagnosis is typically confirmed by coronary angiography, if the angiographic appearance is unclear, use intracoronary imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) to confirm the presence of intramural hematoma or double lumen. 1
Medical Therapy (First-Line Treatment)
Beta-Blockers (Cornerstone of Therapy)
Initiate beta-blockers immediately in all patients unless contraindicated, as they are strongly associated with reduced risk of recurrent SCAD. 1, 2, 3 Continue indefinitely for recurrence prevention. 2
Aggressive Blood Pressure Control
Target systolic BP 120-130 mmHg (or 130-140 mmHg given his age >60 years) using ACE inhibitors, ARBs, or non-dihydropyridine calcium channel blockers, as hypertension is an independent predictor of recurrent SCAD. 4, 1, 2, 3
Antiplatelet Therapy
Prescribe dual antiplatelet therapy (DAPT) with aspirin and clopidogrel in most cases. 5 Avoid potent P2Y12 inhibitors (ticagrelor, prasugrel) as they may favor hematoma propagation. 5 If no stent was placed and patient has no high-risk angiographic features (thrombus burden, critical stenosis, decreased flow), aspirin monotherapy may be considered. 5
Additional Medications
- Statins may be considered for their pleiotropic properties, though evidence is limited in SCAD. 5
- ACE inhibitors or ARBs if left ventricular ejection fraction is reduced below 50% or heart failure symptoms present. 5
Medications to AVOID
Do NOT use fibrinolytic agents or anticoagulants as they could favor hematoma propagation. 5
Revascularization Indications (Reserved for High-Risk Features Only)
Consider revascularization ONLY if:
- 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 2
If revascularization is necessary:
- PCI for focal, accessible lesions with ongoing ischemia 1
- CABG for left main or multivessel involvement, especially when PCI is technically challenging 1
- If stent placed, continue DAPT for 12 months 5
Screening for Associated Conditions
Systematically screen for fibromuscular dysplasia (FMD), as it is present in up to 72% of SCAD patients. 2, 3 Consider vascular imaging from brain to pelvis, with annual non-invasive imaging of carotid arteries initially. 2, 3
Long-Term Management
- Continue beta-blocker therapy indefinitely 2, 3
- Implement stress management techniques, as SCAD is often precipitated by emotional or physical stress 2, 3
- Consider coronary CT angiography (CCTA) for follow-up in patients with persistent or recurrent symptoms 1, 2
- Annual monitoring of lipids, glucose metabolism, and creatinine 4
Special Considerations for This Male Patient
While SCAD is more common in women (90.5%), it does occur in men and should not be dismissed. 1 The same conservative management principles apply, though the absence of pregnancy-related or hormonal factors may influence the underlying etiology. 6, 7 Ensure comprehensive evaluation for underlying arteriopathy, connective tissue disorders, or systemic inflammatory conditions. 6, 7