Initial Management of Spontaneous Coronary Artery Dissection
Conservative medical management is the preferred initial approach for clinically stable SCAD patients, as revascularization carries a 50% failure rate even in those with preserved coronary flow. 1, 2
Risk Stratification and Treatment Algorithm
For Clinically Stable Patients (Most Cases)
- Initiate conservative therapy with inpatient monitoring for 3-5 days to observe for early complications or SCAD progression, which occurs in approximately 10% of conservatively managed patients. 1, 3
- Start dual antiplatelet therapy with aspirin for at least 12 months plus clopidogrel for 1-12 months after the index event. 1, 2
- Initiate beta-blocker therapy immediately, as this has been associated with reduced risk of recurrent SCAD. 3, 4
- Implement aggressive blood pressure control, as hypertension independently predicts recurrent SCAD. 3, 4
For High-Risk Anatomy (Left Main or Proximal 2-Vessel Dissection)
- Consider CABG as the preferred revascularization strategy for left main or severe proximal 2-vessel dissection, though conservative management may still be reasonable in stable patients (not well-studied). 1
- Conservative therapy remains an option even with concerning angiographic appearance if the patient is hemodynamically stable and without ongoing ischemia. 1, 2
For Actively Ongoing Ischemia or Hemodynamic Instability
- Consider PCI only if technically feasible based on local expertise, recognizing the high failure rate. 1
- Proceed to urgent CABG if PCI is not feasible or fails, particularly when dissection starts at the ostium where true lumen identification is difficult. 1, 2
- Emergency CABG is required in approximately 13% of stable SCAD patients who undergo attempted PCI. 1, 2
Critical Management Pitfalls
Avoid Routine Revascularization
- PCI failure rates approach 50-53% in SCAD, even in patients presenting with normal coronary flow at baseline. 1, 2, 5
- Revascularization does not reduce rates of target vessel revascularization (30% vs 19%, p=0.06) or recurrent SCAD (23% vs 31%, p=0.7) compared to conservative management. 5
- Revascularization as first-line therapy increases the risk of target vessel revascularization by an additional 6.3% compared to conservative management. 6
Limit Intravascular Imaging
- Use OCT or IVUS only if the decision to revascularize has already been made, as any attempt at intravascular imaging can trigger abrupt vessel closure. 1, 2
- For diagnostic confirmation when uncertainty exists, CT coronary angiography is safer than intracoronary imaging, especially for proximal lesions. 1, 3
Special Considerations for SCAD Population
- SCAD affects women in over 90% of cases, typically young patients without traditional atherosclerotic risk factors. 2, 4
- Screen for fibromuscular dysplasia using CT/MRA angiographic imaging of renal and carotid arteries, as FMD is present in up to 72% of SCAD patients. 2, 3
- Address emotional and physical stress triggers, as SCAD is often precipitated by stress, and implement stress management techniques for long-term care. 2, 3
Post-PCI Management (If Revascularization Performed)
- For patients who received DES implantation, administer aspirin plus ticagrelor (or prasugrel) for one year, followed by aspirin alone. 1, 2
- When switching from clopidogrel to ticagrelor, give a loading dose of 180 mg ticagrelor. 1, 2
- Consider follow-up angiography at 2-6 months for left main involvement to monitor for restenosis. 3