Management of Spontaneous Coronary Artery Dissection with Fibromuscular Dysplasia

Initial Management

The American College of Cardiology recommends conservative medical management as the preferred initial approach for clinically stable patients with spontaneous coronary artery dissection (SCAD) and fibromuscular dysplasia (FMD), with beta-blockers and aggressive blood pressure control as the cornerstone of therapy 1
Clinically stable patients without high-risk features should be managed conservatively, avoiding revascularization unless absolutely necessary, and monitored as inpatients for 3-5 days to observe for early complications 1

Beta-blockers are strongly recommended as they reduce the risk of recurrent SCAD, particularly important given that FMD is associated with SCAD in up to 72% of cases 1, 2
Aggressive anti-hypertensive therapy is essential, as hypertension is an independent predictor of recurrent SCAD, using ACE inhibitors, ARBs, or non-dihydropyridine calcium channel blockers to achieve normal blood pressure and reduce arterial wall stress 1, 2, 3, 4

Annual non-invasive imaging of the carotid arteries is reasonable initially to detect changes in FMD extent or severity, with studies repeated less frequently once stability is confirmed 3, 4, 5
Platelet inhibitor medication is beneficial for FMD of the carotid arteries to prevent thromboembolism, though optimal dosing is not established 3, 4, 5
Revascularization is NOT recommended for asymptomatic FMD of a carotid artery, regardless of stenosis severity, and should only be considered if the patient develops retinal or hemispheric cerebral ischemic symptoms related to FMD 3, 4, 5

Long-term beta-blocker therapy should be continued to prevent SCAD recurrence 1, 2
Stress management techniques should be implemented, as SCAD is often precipitated by emotional or physical stress 2