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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Spontaneous coronary artery dissection

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Manage suspected SCAD as ACS with urgent cardiology and angiography expertise. Ongoing ischaemia, left-main or proximal critical disease, cardiogenic shock, ventricular arrhythmia or cardiac arrest may require emergency PCI or CABG despite higher technical risk.

Synopsis

Recognise SCAD as a non-atherosclerotic cause of ACS, avoid harmful reflex intervention and provide conservative, multidisciplinary follow-up when the patient is stable.

  • SCAD is separation within the coronary arterial wall caused by intramural haematoma or an intimal disruption, not plaque rupture, trauma or an iatrogenic tear.
  • Consider it in ACS at any age or sex, particularly in younger or middle-aged women, pregnancy or postpartum presentations and patients without conventional atherosclerotic risk factors.
  • Coronary angiography is the usual diagnostic test; long smooth narrowing is common and can be mistaken for spasm or atherosclerosis.
  • Thrombolysis is contraindicated once SCAD is diagnosed because it can extend the dissection or cause coronary rupture and tamponade.
  • Stable patients with preserved flow and no ongoing ischaemia are usually managed conservatively because spontaneous healing is common and PCI has higher failure and propagation risk.
  • Use intracoronary OCT or IVUS only when diagnostic uncertainty will change management; instrumentation can extend the dissection.
  • Antiplatelet therapy after conservatively managed SCAD is not evidence-equivalent to plaque-rupture ACS and should be individualised; standard DAPT is required after stenting unless bleeding forces modification.
  • Assess ventricular function, offer SCAD-informed cardiac rehabilitation and screen for associated extracoronary arteriopathy through a specialist pathway.
  • Future pregnancy, contraception, migraine vasoactive drugs, recurrence fears and psychological recovery require planned multidisciplinary review.

Key red flags

SCAD-pattern ACS

Acute chest pain with ECG change or troponin rise in a person without the expected atherosclerotic profile; pregnancy or postpartum status and emotional or physical stressors can be clues but are not required.

High-risk SCAD

Ongoing ischaemia, poor flow, proximal or left-main involvement, shock or malignant arrhythmia lowers the threshold for revascularisation.

Early extension

Recurrent pain with new ECG change or haemodynamic deterioration during observation can indicate propagation or recurrent SCAD and needs immediate reassessment.

Investigation priorities

01
Serial ECG and high-sensitivity troponinFirst step

Diagnose ACS, localise ischaemia and detect recurrence.

Management branches

Preferred routeAcute diagnosis

ACS where SCAD is plausible

  1. Treat as an emergency ACS, obtain serial ECG and troponin and involve interventional cardiology early.
  2. Perform coronary angiography with SCAD-aware technique; avoid assuming a focal lesion is atherosclerotic in a low-risk phenotype.
  3. Use intracoronary imaging only if uncertainty will change treatment and the procedural risk is acceptable.
  4. Assess LV function and monitor for recurrent pain, ECG change, arrhythmia and haemodynamic deterioration.
Preferred routeConservative management

Stable patient, preserved coronary flow and no ongoing ischaemia or high-risk anatomy

  1. Avoid routine PCI and observe in hospital because early extension or recurrent ischaemia can occur; expert practice commonly uses several days, often 3–5, individualised to presentation.
  2. Stop therapeutic anticoagulation once SCAD is confirmed unless there is another compelling indication, after senior review.
  3. Individualise antiplatelet therapy, blood-pressure control and LV-dysfunction treatment; do not automatically copy atherosclerotic ACS regimens.
  4. Repeat angiography only for clinical deterioration or a management-changing question, not simply to document healing.

Key medicines

AspirinAfter the acute 300 mg load, a common conservative regimen is 75 mg once daily, but duration after non-stented SCAD must be individualised by a SCAD specialist.Evidence for routine long-term therapy in non-stented SCAD is observational; consider bleeding and heavy menstrual bleeding and do not imply a universal duration.
ClopidogrelWhen a stent is placed, use the PCI protocol loading dose, commonly 600 mg orally, then 75 mg once daily with aspirin for the specialist-defined duration.Bleeding, planned surgery and concomitant anticoagulation; the antiplatelet choice and duration should reflect stent and ACS guidance plus SCAD-specific risk.
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Sources and review status9 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • ESC-ACCA position paper on spontaneous coronary artery dissection
  • ESC 2023 Guidelines for acute coronary syndromes
  • ESC clinical review: Spontaneous coronary artery dissection
  • NICE NG185: Acute coronary syndromes (scope notes that SCAD is not covered)
  • ESC 2025 Guidelines for cardiovascular disease and pregnancy
  • Bisoprolol 5 mg tablets SmPC
  • Glyceryl trinitrate 400 micrograms spray SmPC
  • NHS: Common questions about glyceryl trinitrate
  • NICE NG238: Cardiovascular disease risk assessment and lipid modification

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom