Current evidence and future directions in antiplatelet therapy for spontaneous coronary artery dissection: balancing ischemic and bleeding risks

Spontaneous coronary artery dissection (SCAD) has emerged as an increasingly recognized cause of acute coronary syndromes (ACSs), particularly in young women without traditional atherosclerotic risk factors. While conservative management has become the preferred strategy in most stable patients, the role of antiplatelet therapy in this unique setting remains uncertain. Current clinical practice often extrapolates from ACS guidelines, recommending aspirin monotherapy or dual antiplatelet therapy, despite a paucity of direct evidence. Observational registries have provided conflicting results, with some suggesting a benefit of antiplatelet therapy in reducing recurrent ischemic events, whereas others highlight the potential risks of intramural hematoma propagation and bleeding. This review aims to critically examine the available literature on antiplatelet therapy following conservatively managed SCAD, highlighting mechanistic rationale, guideline perspectives, registry data, and evolving clinical approaches. The discussion emphasizes the need for individualized therapy, the limitations of current evidence, and the urgent requirement for randomized controlled trials to establish optimal antiplatelet strategies in this unique population.