Spontaneous coronary artery dissection and sudden cardiac arrest: a reversible event or an indication for secondary prevention?

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly in young women. A high-risk subset of these patients presents with cardiac arrest (CA), creating a profound clinical management dilemma. Current guidelines for secondary prevention with an implantable cardioverter-defibrillator (ICD) offer limited guidance for life-threatening ventricular arrhythmias (VA) secondary to putatively 'reversible' causes such as SCAD. This review critically analyzes the evidence for and against ICD implantation. While the observed rate of appropriate ICD therapy in SCAD survivors is low, the risk of recurrent SCAD is significant (10-30%). Although the acute dissection may heal, the underlying systemic arteriopathy represents a persistent, nonreversible substrate. Therefore, for a selected, high-risk cohort of SCAD patients presenting with CA, the event might be considered a marker for a durable arrhythmic substrate. In these cases, an ICD implantation for secondary prevention should be considered after a comprehensive risk assessment and shared decision-making.