Spontaneous coronary artery dissection
Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic tear or intramural hematoma of a coronary artery causing acute coronary syndrome, predominantly in younger women. Because most cases heal spontaneously, management favors a conservative strategy over routine stenting, reserving intervention for ongoing ischemia or instability.
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What this article covers
- Overview
Definition: spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-atherosclerotic separation of the coronary artery wall (an intimal tear or intramural hematoma) that narrows the lumen and causes myocardial ischemia.
- Epidemiology
Predominantly affects women, including in the peripartum period.
- Risk factors
Female sex (especially perimenopausal and peripartum).
- Pathophysiology
Intramural hematoma or intimal tear: bleeding within the arterial wall (or an intimal disruption) creates a false lumen that compresses the true lumen.
- Clinical features
Acute coronary syndrome: chest pain, often with troponin elevation and ischemic ECG changes (including ST elevation).
- Differential diagnosis
Atherosclerotic acute coronary syndrome: ischemic chest pain with a plaque-based culprit lesion, distinguished by atherosclerotic stenosis and calcification on angiography rather than an intramural…
- Diagnosis
Establish with coronary angiography, using intracoronary imaging when the angiogram is not diagnostic: the diagnostic basis is coronary angiography demonstrating the dissection or intramural hematoma…
- Management
First-line, conservative management for stable patients: because most dissections heal spontaneously, manage stable patients medically with monitoring, a beta-blocker (metoprolol 25 to 100 mg PO…
- Complications
Recurrent myocardial infarction and dissection.
- Prognosis
Most heal spontaneously with a good outcome.
- Prevention
Blood pressure control and a beta-blocker to reduce recurrence (target below 130/80 mmHg).
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