Treatment of Spontaneous Coronary Artery Dissection (SCAD)

Diagnosis Confirmation

SCAD is defined as a non-atherosclerotic, non-traumatic separation of coronary arterial layers creating a false lumen and downstream myocardial ischemia 1
Diagnosis is typically confirmed by coronary angiography, with three angiographic types:
- Type 1: Contrast dye staining with multiple radiolucent lumens 3
- Type 2: Long diffuse and smooth narrowing 3
- Type 3: Focal stenosis mimicking atherosclerosis 1, 3
In unclear cases, intracoronary imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is recommended to confirm the presence of intramural hematoma or double lumen 1, 2

For clinically stable patients without high-risk features, conservative medical therapy is recommended by the European Society of Cardiology 1, 2
Monitor stable patients as inpatients for 3-5 days to observe for early complications 2, 4
Revascularization (PCI or CABG) should be considered only in the following scenarios:
- Hemodynamic instability 4
- Left main or proximal two-vessel coronary dissection with critical flow limitation 1, 2, 4

Beta-blockers are strongly recommended as they have been associated with reduced risk of recurrent SCAD by the European Heart Society 1
Aggressive anti-hypertensive therapy is recommended as hypertension is an independent predictor of recurrent SCAD by the European Heart Society 1

If revascularization is necessary, consider:
- PCI for focal, accessible lesions with ongoing ischemia 4
- CABG for left main or multivessel involvement, especially when PCI is technically challenging 2, 4

Long-term beta-blocker therapy should be continued to prevent recurrence by the European Heart Society 1
Consider coronary CT angiography (CCTA) for follow-up in patients with persistent or recurrent symptoms 1, 3

SCAD is more common in women (90.5%), particularly those under 60 years of age by the European Heart Society 1