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Acute coronary syndrome — MCCQE Part 1 MCQ

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HardChest PainAcute coronary syndromeMCCQE Part 1

A 42-year-old postpartum woman presents with a non-ST-elevation myocardial infarction. Angiography shows spontaneous coronary artery dissection in a distal obtuse marginal branch with preserved flow. She is pain-free, haemodynamically stable, and has no left-main or proximal multivessel involvement. What is the most appropriate coronary strategy?

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Correct answer: A — Conservative inpatient management with close monitoring

Stable SCAD with preserved coronary flow, resolved symptoms, and no left-main or other high-risk anatomy is usually managed conservatively under inpatient observation. Most conservatively managed lesions heal, whereas PCI can propagate the intramural haematoma, wire the false lumen, or require unexpectedly long stents. Revascularisation is reserved for ongoing or recurrent ischaemia, haemodynamic instability, malignant arrhythmia, or threatened substantial myocardium from high-risk anatomy. Fibrinolysis can worsen intramural bleeding and should not be used for SCAD. Routine bypass or prophylactic PCI adds procedural risk without benefit in this stable distal lesion. Immediate discharge is inappropriate because early extension or recurrent events can occur.

Reference: American Heart Association Scientific Statement, Spontaneous Coronary Artery Dissection: https://pmc.ncbi.nlm.nih.gov/articles/PMC5957087/