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SCAD Diagnosis and Management — EECC MCQ

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ModerateCoronary Artery DiseaseSCAD Diagnosis and ManagementEECC

A 50-year-old woman presents with acute chest pain. Her ECG shows ST elevation in leads I, aVL, V5-V6 with reciprocal ST depression in III, aVF. Coronary angiography shows no obstructive disease but a long dissection flap in the mid-LAD. What is the diagnosis?

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Correct answer: E — Spontaneous coronary artery dissection (SCAD) — a non-atherosclerotic cause of ACS that predominantly affects young to middle-aged women; conservative management is first-line unless there is ongoing ischaemia, haemodynamic instability, or left main involvement

SCAD accounts for 1-4% of all ACS cases but 10-25% of ACS in women <60 years. Features: (1) non-atherosclerotic — the intimal-medial dissection creates a false lumen compressing the true lumen; (2) predominantly affects women (>90%), particularly: peripartum, fibromuscular dysplasia (FMD — present in 50-80% of SCAD), connective tissue disorders; (3) angiographic types: Type 1 (arterial wall staining with contrast), Type 2 (diffuse smooth narrowing — most common, ~67%), Type 3 (mimics atherosclerosis — requires IVUS/OCT). The 2023 ESC ACS Guidelines recommend: (1) conservative management is preferred (coronary arteries heal spontaneously in most cases — PCI risks propagating the dissection); (2) PCI/CABG reserved for: ongoing ischaemia, haemodynamic instability, left main dissection; (3) screen for FMD (renal, cerebrovascular); (4) recurrence rate ~10-30% over 5 years.

Reference: ESC (2023): ACS Guidelines