Abstract <p>Spontaneous coronary artery dissection (SCAD) is an important etiology of acute myocardial infarction (AMI). Although far less common than atherosclerotic plaque rupture, it is frequently underrecognized and making an accurate diagnosis is of utmost importance since the management is so distinct from atherosclerotic/thrombotic myocardial infarction.</p> Purpose of Review <p>To evaluate the pathophysiologic and clinical challenges of making a SCAD diagnosis. We also sought to review the newest studies evaluating the optimal management options for SCAD.</p> Recent Findings <p>Part of the reason why SCAD management is difficult is because of the paucity of data. There are no randomized trials that investigate coronary interventions compared to medical therapy. We heavily rely on large registry data and outcomes data from national health databases. In cases with a high pretest probability of SCAD, classic angiographic findings and clinical stability without high-risk anatomy, conservative management of these lesions is typically associated with better outcomes. The rates of spontaneous healing of these SCAD lesions over time is high. Moreover, the anatomic and pathophysiologic challenges of SCAD lesions cause high failure rates of percutaneous coronary intervention.</p>