Concise review for cliniciansWhat Clinicians Should Know Αbout Spontaneous Coronary Artery Dissection
Section snippets
SCAD Presentation and Diagnosis
SCAD presents primarily as non–ST-elevation MI and ST-elevation MI. SCAD can also present as unstable angina or sudden cardiac death.1, 10 Patients are usually women (74%-92% in published series1, 2, 3, 10) with a mean age of 42 to 52 years (Table).1, 10 Typical presenting symptoms are consistent with ACS, including chest pain, dyspnea, diaphoresis, and/or nausea. Diagnostic findings include abnormal electrocardiographic findings, elevated cardiac biomarkers, and regional wall motion
Short-term Management
Correctly diagnosing SCAD is critical because the recommended short-term management differs from guidelines for ACS due to atherosclerotic disease.1, 14 In particular, patients with SCAD have notably elevated rates of complications from percutaneous coronary interventions (PCIs), even in those who present with preserved coronary blood flow.1, 10, 14 In a series that retrospectively reviewed short-term management strategies of 189 patients, 50% of patients with SCAD presenting with normal or
Associated Conditions
The underlying pathogenesis of SCAD remains unclear. Traditional atherosclerotic risk factors are not common among patients with SCAD. Rather, associated clinical conditions include peripartum status, discrete episodes of extreme exercise or emotion, and connective tissue diseases, such as Marfan syndrome, Ehlers-Danlos syndrome type IV, and Loeys-Dietz syndrome.1 Some of these patients are fit athletes who regularly exercise without any other clear predisposing factors.17 Increased coronary
Long-term Management
Much remains to be learned about long-term management of patients with SCAD. Because patients are at risk for future events, including recurrent SCAD, MI, congestive heart failure, or target vessel revascularization,14 regular follow-up is pertinent. Follow-up after the initial hospitalization and cardiac rehabilitation (CR) period usually consists of annual visits with an electrocardiogram and comprehensive history and physical examination. Earlier or more frequent visits are indicated,
Conclusion
SCAD is an important cause of sudden cardiac death and ACS, particularly in young women. Increased awareness and accurate diagnosis of SCAD are important because the short-term and long-term management strategies differ from those for typical atherosclerotic disease. SCAD has been associated with extreme exercise, emotion, and the peripartum state. Extracoronary vascular abnormalities, including fibromuscular dysplasia, are common and may represent an underlying systemic vasculopathy. Imaging
References (31)
- et al.
Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment
Int J Cardiol
(2005) - et al.
Diagnosis of spontaneous coronary artery dissection by optical coherence tomography
J Am Coll Cardiol
(2012) - et al.
Endovascular imaging of angiographically invisible spontaneous coronary artery dissection
JACC Cardiovasc Interv
(2012) - et al.
Nonatherosclerotic coronary artery disease in young women
Can J Cardiol
(2014) - et al.
Spontaneous coronary artery dissection and eosinophilic inflammation: a cause and effect relationship?
Am J Med
(1982) - et al.
Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a “conservative” therapeutic strategy
J Am Coll Cardiol Cardiovasc Interv
(2012) - et al.
A novel application of CT angiography to detect extracoronary vascular abnormalities in patients with spontaneous coronary artery dissection
J Cardiovasc Comput Tomogr
(2014) - et al.
Spontaneous coronary artery dissection: prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort
J Am Coll Cardiol Cardiovasc Interv
(2013) - et al.
Barriers to participation in cardiac rehabilitation
Am Heart J
(2009) - et al.
Spontaneous coronary artery dissection: a disease-specific, social networking community-initiated study
Mayo Clin Proc
(2011)
Clinical features, management, and prognosis of spontaneous coronary artery dissection
Circulation
Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients
Eur J Cardiothorac Surg
Spontaneous coronary artery dissection: a Western Denmark Heart Registry study
Catheter Cardiovasc Interv
Pregnancy-associated acute myocardial infarction: a review of contemporary experience in 150 cases between 2006 and 2011
Circulation
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Secondary Prevention and Rehabilitation for Spontaneous Coronary Artery Dissection: A Systematic Review
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2023, Current Problems in CardiologyCitation Excerpt :Case 1 in our series was managed with conservative therapy with good outcomes. Revascularization should be considered in patients with hemodynamic instability, persistent symptoms, and in multivessel disease or left main coronary artery (LMCA) involvement.9 Options for revascularization include CABG and percutaneous coronary intervention (PCI).
Spontaneous coronary artery dissection
2021, Revista Clinica EspanolaCardiac Computed Tomography to Identify and Guide Therapy of Intramural Hemorrhage in High-Risk Coronary Anatomy
2021, JACC: Case ReportsCitation Excerpt :IMH can be formed either by an intimal tear resulting in blood from the endoluminal space entering the intimal space or due to rupture of the vasa-vasorum, which are specialized micro-vessels within the walls of arteries supplying blood to the walls (1). SCAD is usually diagnosed on invasive coronary angiography; intracoronary imaging (such as IVUS) can be used for confirmation in indeterminate cases, often by visualizing an IMH (2). The use of CTCA was previously reported in only a limited number of cases.
Women With Spontaneous Coronary Artery Dissection Are at Increased Risk of Iatrogenic Coronary Artery Dissection
2021, Heart Lung and CirculationCitation Excerpt :It affects females disproportionately, for example 92.3% of a large 2014 SCAD case series were female [1]. SCAD is difficult to distinguish clinically from atherosclerotic ACS, based on symptoms, electrocardiographs (ECGs) and biomarkers [3]; however, it has a distinct pathophysiology and demographic profile. In particular, patients with SCAD tend to be younger, are much more likely to be female, and less likely to have traditional atherosclerosis risk factors than patients with atherothrombosis [1].
Fibromuscular Dysplasia: Recognition and Management
2019, Journal for Nurse Practitioners
Grant Support: The “Virtual” Multicenter Spontaneous Coronary Artery Dissection (SCAD) Registry and DNA biorepository are funded in part by Mayo Clinic Division of Cardiovascular Diseases and SCAD Research Inc.