Spontaneous coronary artery dissection: to do good or to do no harm?

‘First, do no harm’ are oft misquoted words from Hippocrates’ 2500-year-old work Epidemics . A more complete and accurate translation of his exhortation reads: > The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.1 This is laudable sentiment but is it realistic for a diagnosis surrounding which much uncertainty remains? Looking back only 20 years, a case report in this publication described spontaneous coronary artery dissection (SCAD) as ‘an extremely rare cause of unstable angina and acute myocardial infarction’.2 That is no longer the case. There has been a surge in the recognition of the condition. One recent study found 33 (2.4%) cases of SCAD among 1375 patients who underwent invasive coronary angiography for acute coronary syndrome in 2019.3 This represents a 10-fold increase in relative diagnostic frequency since an earlier registry (1999–2007) identified only 22 (0.2%) cases from 11 175 patients.4 Presuming that the true incidence is unchanged, this growth reflects a remarkable ‘paradigm shift in clinical appreciation’.5 In contrast to many cardiovascular disorders, SCAD is predominantly a disease affecting middle-aged women with comparatively few traditional atherosclerotic risk factors. The epidemiology, pathophysiology and approach to diagnosis of SCAD have been informed by retrospective observational cohort studies but optimal management remains unclear. Invasive coronary angiography represents the primary imaging modality for identifying the condition, meaning definitive treatment decisions are commonly made in the catheter laboratory and herein lies the challenge. In contrast with atherosclerotic disease, percutaneous coronary intervention (PCI) is associated with less predictable outcomes in …