The following are key points to remember about this state-of-the-art review on spontaneous coronary artery dissection (SCAD): pitfalls of angiographic diagnosis and an approach to ambiguous cases.

1. Appropriate management of SCAD is predicated on an accurate diagnosis. Management is different from acute coronary syndrome secondary to atherosclerosis with a conservative approach favored over percutaneous coronary intervention.
2. Clinical features favoring SCAD include history of fibromuscular dysplasia or connective tissue disease, pregnancy-associated myocardial infarction, and nonresponsiveness to intracoronary nitrates. SCAD is almost exclusively seen in women <50 years old (90%). Men and older ages rarely present with SCAD and this diagnosis should be carefully considered for this population.
3. The Yip-Saw angiographic classification of SCAD divides it into three types: In type 1 SCAD, contrast penetrates into the false lumen and there may be dye ‘hang up.’ Less than one-third of SCAD presents as type 1 and can suggest late presentation. Type 1 is less likely to progress and best managed conservatively.
4. Type 2 SCAD is the most common and appears as a long smooth stenosis.
5. Type 3 SCAD mimics atherosclerosis and requires intracoronary imaging to make the distinction.
6. Other features that suggest SCAD over atherosclerosis include presence of tortuous vessels, lack of involvement of branching points, and absence of thrombus.
7. Mimickers of SCAD include takotsubo cardiomyopathy, coronary embolus, contrast streaming, or coronary vasospasm.
8. Three approaches to help distinguish SCAD from atherosclerosis in ambiguous cases include presence of luminal thrombus (atherosclerosis), intracoronary imaging, and coronary computed tomography angiography.
9. The classic intravascular ultrasound feature of SCAD is the triple band (white-black-white) of the intimal-media membrane and is pathognomonic for SCAD. Optical coherence tomography is preferred due to its higher spatial resolution and better ability to visualize the intimal medial membrane, false lumen, and external elastic membrane.
10. Screening for extracoronary arteriopathies with brain to pelvis imaging is recommended.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Echocardiography/Ultrasound, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Atherosclerosis, Coronary Angiography, Coronary Stenosis, Coronary Vasospasm, Diagnostic Imaging, Dissection, Embolism, Fibromuscular Dysplasia, Myocardial Infarction, Percutaneous Coronary Intervention, Pregnancy, Takotsubo Cardiomyopathy, Tomography, Optical Coherence, Ultrasonography, Interventional, Women

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