Treatment Options for Coronary Artery Dissection

Treatment Algorithm Based on Clinical Presentation

The European Society of Cardiology recommends a conservative approach for spontaneous coronary artery dissection (SCAD) without ongoing ischemia, regardless of angiographic appearance 1, 4
Conservative management is indicated when coronary flow is normal and the patient is hemodynamically stable, with better outcomes than percutaneous coronary intervention (PCI) in stable SCAD cases 3, 5
The European Society of Cardiology suggests that PCI has approximately 50% failure rate in stable SCAD cases 2
Antiplatelet therapy with aspirin for at least 12 months plus clopidogrel for 1-12 months is recommended for conservatively managed SCAD 1
For SCAD treated with drug-eluting stent (DES), antiplatelet therapy with aspirin plus ticagrelor or prasugrel for one year, followed by aspirin alone is recommended 2, 3
When switching from clopidogrel to ticagrelor, a loading dose of 180 mg ticagrelor should be administered 3, 6

Spontaneous coronary artery dissection (SCAD) affects women in over 90% of cases, often precipitated by emotional or physical stress, and is associated with fibromuscular dysplasia in up to 72% of cases 1, 7
PCI for SCAD has high failure rates (approximately 50%), even in cases with normal coronary flow at baseline 1, 2
Intravascular imaging can trigger abrupt vessel closure if used inappropriately 2, 3
Dissections starting at the ostium with difficult true lumen identification carry higher risk for abrupt occlusion during PCI 4, 5

Close monitoring is essential as both SCAD and complications can recur, and stress management techniques are recommended as SCAD is often precipitated by stress 7