Table 1.
Suggested diagnostic and therapeutic management of SCAD
| Clinical management | Suggested approach |
|---|---|
| Diagnosis | |
| Invasive angiography | Angiographic appearances diagnostic in most cases (Figure 3). Careful technique due to increased risk of iatrogenic dissection |
| Optical coherence tomography (OCT) | Useful and low risk in cases where angiographic appearances are non-diagnostic or to guide PCI |
| Intravascular ultrasound | Lower spatial resolution than OCT. Alternative when OCT unavailable |
| Computed tomography | Lower spatial resolution than angiography. May be helpful where non-invasive follow-up is required of proximal or mid-vessel disease |
| Revascularization | |
| PCI | Reserved for cases with high myocardial jeopardy at presentation (e.g. occlusive SCAD). Long segments of small calibre stents often needed |
| CABG | Reserved as bail-out for high-risk scenarios. Increased risk of early graft failure over time. |
| Conservative | Good outcomes with healing, restoration of coronary architecture and small myocardial injuries in most non-occlusive cases |
| Thrombolysis | Isolated reports of complications. Not the preferred management option in SCAD |
| Medical management | |
| Clopidogrel/P2Y12 inhibitors | In cases managed with PCI, manage according to guidelines. In conservatively managed SCAD, limited observational data suggest increased risk of dual over monotherapy. Clinical trial data awaited |
| Aspirin | Use as long-term prophylaxis is controversial. Clinical trial data awaited |
| Statin | No current evidence to suggest a benefit of statins after SCAD outside primary prevention guidelines |
| Beta-blockers | Use according to guidelines in patients with LVSD after SCAD. Use of beta-blockers and control of hypertension may reduce the risk of recurrent SCAD. Clinical trial data awaited |
| ACE inhibitors/ARB | Use according to guidelines in patients with LVSD post-SCAD or to control hypertension |
ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers; CABG, coronary artery bypass grafting; LVSD, left ventricular systolic dysfunction; PCI, percutaneous coronary intervention; SCAD, spontaneous coronary artery dissection.