The management of SCAD remains relatively unexplored. There are no randomised trials comparing conservative treatment with revascularisation. Furthermore, standard medications administered for cardiac patients have not been studied in the SCAD population. Thus, recommendations on SCAD management remain empiric and largely based on expert opinion. The rationale and strategy of pharmaceutical therapy for SCAD was previously reviewed in detail.8 In essence, aspirin and beta-blocker are administered long-term for secondary thrombotic prevention and reduction of arterial shear-stress, respectively. ACE inhibitor is administered for patients with left ventricular dysfunction and statins for patients with underlying dyslipidemia. In terms of revascularisation, the expert consensus is conservative management unless patients have ongoing/recurrent ischaemia, haemodynamic instability, or left main dissection, since invasive management with coronary stenting is often challenging and can have suboptimal results (procedural success in 50–70 %).1,9 The results of long-term outcome with bypass grafting are inconclusive as they are derived from small case series of <15 patients; nevertheless, there is concern over graft patency with one study showing ~75 % of grafts occluded at follow-up.1
Recent series of prospectively followed SCAD patients have provided important information on acute and long-term cardiovascular outcomes. Most patients present with acute coronary syndromes with either non- ST elevation or ST-elevation MI and a small proportion have ventricular arrhythmias. Acute in-hospital mortality was relatively low (<5 %) in contemporary series. Recurrent MI or need for revascularisation in initially conservatively managed patients was 5–10 %.1,10 However, following the acute event, a significant proportion of patients have recurrent chest pains (often atypical in features). Subacute major adverse cardiovascular events (MACE) were reported at 10–20 % at 2-year follow-up, with recurrent SCAD event of ~15 %. At longer-term follow-up from retrospective cohorts, estimated rate of MACE can be up to 50–60 %.1,10 Therefore, SCAD survivors should be closely followed by cardiovascular specialists.