Drugs for spontaneous coronary dissection: a few untrusted options

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome that is often overlooked, misdiagnosed, and maltreated. Medical treatment poses a significant challenge because of the lack of randomized studies to guide treatment. The initial clinical presentation should guide medical and interventional management. Fibrinolytic agents and anticoagulants should be avoided because they could favor hematoma propagation. In patients with SCAD, antiplatelet therapy should be prescribed especially dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel, whereas potent P2Y12 inhibitors, e.g., ticagrelor and prasugrel, should be avoided. If a stent was used, DAPT should be continued for 12 months. Aspirin only can be an option for patients without "high-risk" angiographic features-thrombus burden, critical stenosis, and decreased coronary flow. Beta-blocking (BB) agents should be used to prevent recurrence of SCAD. There is a general agreement that angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, mineralocorticoid antagonists, and loop diuretics should be used in patients with SCAD experiencing the symptoms of heart failure and a decrease in left ventricular ejection fraction below 50%. Although without firm evidence, statins can be used in SCAD due to their pleiotropic properties. The results of a randomized trial on the use of BB and statins are awaited. Aggregation of data from national registries might point out truly beneficial medications for patients with SCAD.

Keywords: ACE inhibitor; antiplatelets; beta-blocker; spontaneous coronary dissection; statin.

Figure 1

Coronary angiography and OCT of left anterior descending artery (LAD) SCAD in a 57-year-old lady. (A) Longitudinal OCT image 1 month after initial event with 3D flythrough showing persistent hematoma. (B) OCT cross-sectional image distal to SCAD lesion; (C) OCT cross-sectional at the level of hematoma; (D) OCT cross-section proximal to hematoma; (E) Coronary angiography of LAD [right anterior oblique (RAO)-cranial] at initial hospitalization; (F) Repeated coronary angiography 1 month later.

Figure 2

Proposed algorithm for medical treatment of imaging confirmed SCAD. *“high-risk” features—concomitant atherosclerosis, large thrombus burden, critical stenosis that was left untreated, and significant flow impairment in the affected coronary artery. AF, atrial fibrillation; BNP, brain natriuretic peptide; IV, intravenous; MCS, mechanical circulatory support; MRA, mineralocorticoid receptor antagonist.