Spontaneous coronary artery dissection treatment approach

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Nate Michalak, B.A.
Synonyms and keywords: SCAD

Overview

Acute management of myocardial infarction in SCAD is medical therapy in approximately 80% of the patients. Myocardial infarction in the context of SCAD is different from the myocardial infarction in the context of atherosclerosis and therefore makes it unfavorable for revascularization approaches. Long-term treatment for spontaneous coronary artery dissection pursues several main goals including antianginal therapy, prevention of recurrence, assessment, and management of extra coronary vascular abnormalities, and improvement of quality of life. To improve the quality of life in patients with SCAD, consider cardiac rehabilitation referral and manage patients comorbidities.

Algorithm for management of acute spontaneous coronary artery dissection.^[1]

Management of Acute Spontaneous Coronary Artery Dissection

Clinically stable
without high-risk anatomy

Clinically stable with high-risk anatomy
(i.e., left main or proximal 2-vessel dissection)

Active/ongoing ischemia
or hemodynamic instability

❑ Conservative therapy
❑ Monitor as inpatient 3–5 days

❑ Consider CABG
❑ Conservative Rx may be reasonable

❑ Consider PCI if feasible, OR
❑ Urgent CABG (based on technical considerations and local expertise)

Abbreviations: CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; Rx, management.

Acute management of myocardial infarction in SCAD is medical therapy in approximately 80% of the patients. Myocardial infarction in the context of SCAD is different from the myocardial infarction in the context of atherosclerosis and therefore makes it unfavorable for revascularization approaches.^[2]
Percutaneous coronary intervention (PCI) can be considered in high risk patients, such as:
- Patients with following clinical presentations:
  - Persistent chest pain with evidence of worsening ischemia
  - Hemodynamic instability
  - Shock
  - Ventricular arrhythmias
- Patients with following vascular involvement:
  - Multi-vessel proximal dissections
  - Left main artery dissection
  - Ostial left anterior descending artery dissection
Management with PCI may be associated with several adverse events, including:
- Stent malposition
- Iatrogenic injury to the vessels
- Hematoma
- Coronary vessel occlusion
- Coronary vessel anomaly

Long-term treatment for spontaneous coronary artery dissection pursues several main goals:^[2]
- Antianginal therapy
- Prevention of recurrence
- Assessment and management of extra coronary vascular abnormalities
- Improvement of quality of life

To manage of chest pain in patients with SCAD consider the followings:^[2]
- Antianginal medications
- Consider further testing to rule out underlying ischemia
- Consider other possible diagnoses

To reduce the risk of SCAD recurrence, the following should be considered:^[2]
- Beta-blocker therapy
- Management of hypertension
- Maintaining physical activity

To identify patients with SCAD-associated conditions, imaging with CT angiography or magnetic resonance angiography is recommended.^[2]

To improve the quality of life in patients with SCAD, consider:^[2]
- Cardiac rehabilitation referral
- Manage patients comorbidities

↑ Hayes, Sharonne N.; Kim, Esther S.H.; Saw, Jacqueline; Adlam, David; Arslanian-Engoren, Cynthia; Economy, Katherine E.; Ganesh, Santhi K.; Gulati, Rajiv; Lindsay, Mark E.; Mieres, Jennifer H.; Naderi, Sahar; Shah, Svati; Thaler, David E.; Tweet, Marysia S.; Wood, Malissa J. (2018). “Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association”. Circulation: CIR.0000000000000564. doi:10.1161/CIR.0000000000000564. ISSN 0009-7322.
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Kim, Esther S.H.; Longo, Dan L. (2020). “Spontaneous Coronary-Artery Dissection”. New England Journal of Medicine. 383 (24): 2358–2370. doi:10.1056/NEJMra2001524. ISSN 0028-4793.