Conservative Treatment in Spontaneous Coronary Artery Dissections
Key findings
- Conservative management of SCAD tends to produce favorable outcomes where there are no flow-limiting lesions of major arteries
- Vessel fragility and tortuosity in SCAD patients require a methodical, cautious and careful approach to pursuing PCI
- Peripartum SCAD patients require highly experienced practitioners due to higher risk of technical complications
Spontaneous coronary artery dissection (SCAD) typically presents rapidly and without warning in young, female patients who have little prospective or recognized risk. While uncommon, it is a cardiac emergency and life-threatening event. SCAD requires immediate and astute triage and treatment. Yet study data are lacking on how best to optimally treat and manage SCAD cases.
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Conservative treatment, favorable outcomes
An editorial reviewing a publication in the journal Catheterization Cardiovascular Interventions (CCI) reports on 64 consecutive patients who presented with SCAD over a17-year period in Eastern Switzerland. The editorial, written by Malissa Wood, MD, and Douglas Drachman, MD, from Massachusetts General Hospital, concludes that these data support medical management over percutaneous coronary intervention (PCI) in most SCAD cases.
Of the 64 patients enrolled in the study, 94 were female, and 89% were successfully managed medically.
Most physicians in the study chose to begin with diagnostic coronary angiography. But for treatment, they tended to take a conservative approach in clinically stable patients who:
- Lacked flow-limiting lesions in major arteries
- Had occlusion of a small vessel but without symptoms
- Presented with ST-elevation but who had no flow-limiting lesions at the time of their cardiac catheterization
Lower success of PCI in SCAD
Evidence and support for using a conservative approach in SCAD management has previously been reported. The current study’s data reinforce the evidence base. The study also notes that the use of PCI is associated with significantly lower success, as low as a 62% procedural success rate, compared to PCI performed in other contexts, such as in patients with atherosclerotic CAD.
Two other factors justify conservative SCAD management, according to the editorialists: vessel fragility and complicated tortuosity.
Because SCAD vessels are less robust than normal coronary arteries, they tend to be more vulnerable to progressive iatrogenic injury or to propagation of the dissection during instrumentation. Add to this the incidence of significant vascular tortuosity seen in SCAD patients—as high as 78% in some reports—it becomes clear that greater technical complexity complicates the successful passing of the guidewire. The conservative management approach obviates these risks.
Mastering the angiography of SCAD
The editors note that in the appropriate patient and context, the presence of highly tortuous coronary vessels should raise a practitioner’s clinical suspicion for SCAD. They seek to raise awareness of the valuable diagnostic role of the angiographic appearance of SCAD.
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