Management of Spontaneous Coronary Artery Dissection: when doing less is more

Take Home Messages
  • Clinically stable patients should be managed conservatively with a period of inpatient monitoring
  • Invasive angiography is the mainstay of diagnosis, but carries increased risks of extending existing dissection or causing iatrogenic dissection
  • Revascularisation is high risk and is primarily indicated in patients with ongoing ischaemia, arrhythmias, cardiogenic shock, or possibly left main stem or proximal disease
  • There is no strong evidence for long term therapy to prevent recurrence, or for antiplatelets outside the context of PCI
  • SCAD is associated with underlying arteriopathies, most commonly fibromuscular dysplasia, so screening for extra- coronary vascular abnormalities with CT or MR should be considered

Spontaneous coronary artery dissection (SCAD) is increasingly recognised as an important cause of acute coronary syndrome (ACS), particularly in young and middle-aged women. However, management is distinct from ACS due to atherosclerotic disease. There is a limited evidence base for acute and longer term management and data is entirely based on retrospective and observational studies, with no large scale randomised controlled trials. Based on this limited data and largely expert consensus, position statements have been published by the American Heart Association (1) and the European Society of Cardiology (2). Most recently, a large international cohort study was published in 2021 (3) looking at the role of percutaneous coronary intervention (PCI) in SCAD. This editorial will focus on diagnosis and management, outlining current guidelines and evidence and future areas for research.