What is the recommended treatment for a coronary artery dissection?

Treatment of Coronary Artery Dissection

Conservative medical management is the preferred initial approach for clinically stable patients with spontaneous coronary artery dissection (SCAD), with revascularization reserved only for hemodynamically unstable patients or those with left main/proximal two-vessel involvement. 1, 2, 3

Initial Clinical Assessment and Stabilization

Determine hemodynamic stability immediately – this is the critical decision point that dictates your entire management strategy. 1, 3

For Clinically Stable Patients (Most Common Scenario):

• Choose conservative medical therapy as first-line treatment – this is the American Heart Association's primary recommendation for stable SCAD patients. 1, 2, 3
• Admit for inpatient monitoring for 3-5 days to observe for dissection extension, recurrent ischemia, or hemodynamic deterioration. 1, 2, 3
• Avoid revascularization even if the angiogram looks concerning – the appearance of the vessel does not dictate treatment in stable patients. 1

Critical pitfall: Do not be tempted to intervene based solely on angiographic appearance. PCI in SCAD has approximately 50% failure rate, and instrumentation can trigger abrupt vessel closure. 1

For Hemodynamically Unstable Patients or High-Risk Anatomy:

Proceed to revascularization immediately if any of the following are present: 1, 2, 3

• Active hemodynamic instability
• Ongoing ischemia despite maximal medical therapy
• Left main coronary artery dissection 1, 4
• Proximal two-vessel coronary dissection 1, 4, 3

Choose PCI for: 1, 2, 5

• Focal, accessible lesions with ongoing ischemia
• Single-vessel involvement where the true lumen can be clearly identified

Choose CABG for: 1, 2, 4, 5

• Left main involvement
• Multivessel dissection
• Cases where PCI is technically challenging or the true lumen cannot be accessed
• Dissection starting at the ostium (high risk for abrupt occlusion during PCI) 1

Medical Therapy (Cornerstone of Treatment)

Beta-Blockers (Most Important Medication):

• Initiate beta-blockers in all SCAD patients unless contraindicated – the European Heart Society strongly recommends this as they reduce risk of recurrent SCAD. 2, 3
• Continue indefinitely for recurrence prevention. 2, 3

Aggressive Blood Pressure Control:

• Target aggressive antihypertensive therapy – hypertension is an independent predictor of recurrent SCAD. 2, 3
• Use ACE inhibitors, ARBs, or non-dihydropyridine calcium channel blockers. 3

Antiplatelet Therapy:

• Aspirin is generally safe and beneficial for SCAD patients. 6
• Dual antiplatelet therapy (DAPT) is recommended only for patients undergoing PCI. 1, 6
• For conservatively managed patients, consider short-term DAPT followed by single antiplatelet therapy with aspirin. 6

Medications to AVOID:

• Fibrinolytics are contraindicated – can extend the dissection. 6
• Anticoagulants are contraindicated – can worsen intramural hematoma. 6
• Glycoprotein IIb/IIIa inhibitors are contraindicated. 6
• Avoid exogenous hormones in all SCAD patients. 3

Diagnostic Confirmation

Use intracoronary imaging (OCT or IVUS) only if you have already decided to revascularize – any instrumentation can trigger abrupt vessel closure. 1, 2

The three angiographic types are: 1, 2

• Type 1: Multiple radiolucent lumens or arterial wall contrast staining
• Type 2: Long diffuse smooth narrowing (most common)
• Type 3: Focal stenosis mimicking atherosclerosis (requires imaging confirmation)

Follow-Up and Recurrent Symptoms

For New Acute Coronary Syndrome:

• Perform urgent evaluation per standard ACS guidelines with ECG, troponin monitoring, and imaging. 1, 3
• Consider SCAD progression, recurrent SCAD, or stenosis thrombosis in differential. 1, 3

For Stable Angina After SCAD:

• Evaluate with stress imaging first (echo, CMR, or nuclear perfusion). 1, 3
• If high-risk anatomy or compelling clinical scenario, consider coronary imaging as initial approach. 1, 3
• Consider coronary CT angiography for follow-up in patients with persistent or recurrent symptoms. 2, 3

Screening for Associated Conditions

• Screen all SCAD patients for fibromuscular dysplasia (FMD) – present in up to 72% of SCAD patients. 1, 3
• Consider vascular imaging from brain to pelvis in all SCAD patients. 3
• Annual non-invasive imaging of carotid arteries is reasonable initially. 3

Special Considerations

• SCAD predominantly affects women (>90%), particularly those under 60 years of age. 2, 4, 3
• Emotional or physical stress is often a precipitating factor – stress management techniques are essential. 1, 3
• For pregnancy-associated SCAD, avoid hormones and discourage future pregnancy. 3, 6