Spontaneous Coronary Artery Dissection: Conservative Care or Revascularization
A single patient whose artery is torn, not blocked by plaque, which changes what "fixing it" is even likely to mean. The disagreement is about whether a stent helps a vessel like this or extends the very tear it's meant to repair.
E.V., a 38-year-old woman, is six weeks postpartum with her second child, and was carrying the baby up a flight of stairs when a tight, tearing chest pain stopped her halfway. She has no history of hypertension, diabetes, or smoking, and no family history of premature coronary disease — a genuinely clean cardiovascular profile that, in this specific setting, is itself a real diagnostic clue rather than reassurance. Her troponin came back elevated, and emergent angiography identified a dissection in the mid-LAD rather than any atherosclerotic plaque, with TIMI 3 flow preserved distal to it. She is hemodynamically stable, and her pain has already resolved with conservative measures alone.
Spontaneous coronary artery dissection is not atherosclerotic disease, and that distinction matters directly for what happens next: a stent placed across a dissected, fragile vessel wall can propagate the dissection plane rather than repair it, which is why current guidance for stable patients with preserved distal flow favors conservative management and allows the vessel to heal on its own over the following weeks. Her clinical picture — postpartum, mid-vessel rather than proximal, TIMI 3 flow, no ongoing ischemia — matches the profile in which conservative management has the best track record. The team's job now is deciding whether her case genuinely fits that profile closely enough to avoid a catheter a second time. Registry data on postpartum SCAD specifically also support the conservative approach in a stable patient like her, since the hormonal and hemodynamic shifts of the postpartum period are themselves a recognized trigger, not evidence of an ongoing process that a stent would meaningfully interrupt. Two further steps follow from the diagnosis itself rather than from how this lesion is managed: screening imaging of the renal and cerebrovascular arteries, since fibromuscular dysplasia is found in a substantial share of SCAD patients and changes long-term surveillance, and an explicit conversation about future pregnancy and estrogen-containing contraception, both of which carry recognized recurrence risk after SCAD.
A tear, not a blockage
I'd manage this conservatively. She has everything that predicts a good outcome without a catheter going back in: preserved TIMI 3 flow, a mid-vessel rather than proximal location, and resolved pain without hemodynamic compromise. Stenting a dissected wall risks extending the false lumen the dissection has already created, and the vessel has a real, well-documented capacity to heal on its own over the coming weeks when it looks like hers does.
I don't disagree with the default, but I want us to be precise about why it applies here rather than assuming it does because SCAD is in the chart. If this had been a proximal LAD dissection threatening a large territory, or if her flow had been anything less than TIMI 3, I'd be arguing the opposite. It's worth saying out loud that we're not applying a blanket rule — we're applying it because her specific anatomy earns it.
Agreed, and that's exactly the distinction worth documenting clearly, since the next physician who reads this chart should see why the decision was made, not just what it was.
The medication plan should look different from an ordinary post-stent regimen too. A beta-blocker reduces arterial wall shear stress and has real observational support for reducing SCAD recurrence, so that starts today. For the antiplatelet side, I'd favor aspirin alone over prolonged dual therapy — there's no atherosclerotic plaque here for a P2Y12 inhibitor to be protecting against a stent thrombosis risk from, and extended dual therapy only adds bleeding exposure without a clear benefit in a non-stented dissection. On breastfeeding, which she asked about directly before we'd even finished the plan: metoprolol passes into milk in small amounts and is considered acceptable, and aspirin is compatible only at low antiplatelet doses — 81 mg daily here. Analgesic or anti-inflammatory aspirin doses are a different question in a nursing mother, and are not what we're prescribing.
Managed conservatively, without a second catheterization. Metoprolol and low-dose aspirin monotherapy started, both compatible with breastfeeding at the doses prescribed; repeat imaging planned at several weeks to confirm angiographic healing, with a clear return threshold if chest pain recurs or hemodynamics change in the meantime. Screening for fibromuscular dysplasia arranged, and future pregnancy and estrogen-containing contraception flagged for a dedicated counseling visit.