Key Points
- Favor conservative management when stable; avoid thrombolysis.
- Screen for fibromuscular dysplasia and related arteriopathies.
- Beta‑blockers appear to reduce recurrence; ensure follow‑up.
Algorithm
- Primary survey and stabilization; focused history and exam.
- Order high‑yield tests first; escalate imaging as indicated.
- Initiate disease‑specific therapy and supportive care.
- Reassess clinical response; arrange consultation and disposition.
Clinical Synopsis & Reasoning
Younger women with ACS symptoms, often without classic risk factors; angiography shows coronary dissection not due to atherosclerosis. Prefer conservative therapy in stable patients as healing occurs spontaneously; PCI reserved for ongoing ischemia or left main. Screen for fibromuscular dysplasia and arteriopathies; counsel on recurrence and pregnancy.
Treatment Strategy & Disposition
Single antiplatelet therapy is generally preferred after conservative management; short DAPT may be used post‑PCI. Avoid fibrinolysis. Beta‑blockers reduce recurrence; cardiac rehab and follow‑up imaging advised.
Epidemiology / Risk Factors
- Epidemiology varies by setting; see citations for details.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Coronary angiography ± OCT/IVUS | Define dissection flap/IMH | Types 1–3 SCAD | Use careful technique to avoid propagation |
| CTA head/neck/abdomen | Screen arteriopathies (e.g., FMD) | FMD, aneurysms | — |
| Troponins/ECG | Assess ACS | ↑Troponin, ischemic changes | — |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Aspirin | Antiplatelet | Minutes | Baseline secondary prevention | Bleeding |
| Beta‑blocker | Rate/anti‑shear | Hours | Lower recurrence risk | Bradycardia |
| Clopidogrel (post‑PCI) | P2Y12 inhibitor | Hours | DAPT after stent | Bleeding |
Prognosis / Complications
- Prognosis depends on timeliness of diagnosis, comorbid disease, and response to therapy.
Patient Education / Counseling
- Explain expected course, warning signs requiring urgent care, and follow‑up testing.
- Review medication use, interactions, and monitoring parameters.
References
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