Elsevier

Mayo Clinic Proceedings

Volume 90, Issue 8, August 2015, Pages 1125-1130
Mayo Clinic Proceedings

Concise review for clinicians
What Clinicians Should Know Αbout Spontaneous Coronary Artery Dissection

https://doi.org/10.1016/j.mayocp.2015.05.010Get rights and content

Abstract

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome and sudden death in young persons, particularly women. Associated conditions include fibromuscular dysplasia, peripartum status, and episodes of extreme emotion or exercise. Because of heightened awareness and improved diagnostic accuracy, it is increasingly important for clinicians to understand SCAD. Moreover, short-term and long-term management strategies diverge from typical strategies for atherosclerotic disease. In this Concise Review, we aim to highlight the key points about SCAD, including presentation, diagnosis, associated conditions, and short-term and long-term management.

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

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    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.

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