Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy

Exclusion of a left main pseudo aneurysm complicating SCAD by two overlapping DES - a case report

SCAD is now recognized as an important cause of ACS in women, and its treatment is generally based on conservative therapy leading to complete cure. However, complete cure is not systematic, and data are lacking to identify patients at risk of malignant progression and to define the best therapeutic strategy.A 36-year-old woman with STEMI on SCAD extending from the LM to the middle LAD and circumflex artery, evolving under medical treatment to a large LM pseudo aneurysm. After CT evaluation and IVUS measurement, the patient underwent pseudo aneurysm exclusion by implantation of two overlapping DES on his collar. The choice of conservative treatment in the initial phase, given the extension of SCAD to all left coronary arteries, and the management of this voluminous LM pseudo aneurysm by implantation of two overlapping DES rather than by a covered stent or coil embolization, can be discussed here.

Non-atherosclerotic coronary causes of myocardial infarction in women

Ischemic heart disease is the most common cardiovascular cause of death in women worldwide. Obstructive coronary atherosclerosis is the primary cause of myocardial infarction (MI), however, non-atherosclerotic mechanisms of MI, such as spontaneous coronary artery dissection, vasospasm, microvascular dysfunction, embolization, inflammation, coronary anomalies, infectious and infiltrative causes are increasingly being recognized. Emerging data suggest that women are two to five times more likely to have an MI in the absence of coronary atherosclerosis compared to men, but they continue to remain underdiagnosed and undertreated, partly due to underdiagnosis and limited understanding of these mechanisms. Recent advancements in invasive and noninvasive imaging techniques and physiological testing allow for distinguishing these mechanisms from each other, providing a definitive diagnosis and tailored treatment. This review summarizes the existing literature on the non-atherosclerotic coronary causes of MI with a focus on evidence pertaining to women, offering a basis for future studies.

A Noninvasive Diagnostic Approach for Identifying Spontaneous Coronary Artery Dissection (SCAD) in Young Women: A Case Report and Review of the Literature

A 19-year-old female patient presented with an acute onset of substernal chest pain, accompanied by dyspnea and diaphoresis while walking to the gym. She was able to start her routine, but the pain worsened. She was taken to the emergency room, where an electrocardiogram was performed, and no irregularities were observed, while the troponin test was significantly elevated. Imaging studies, including a Doppler echocardiogram and an emergent CT of the chest to rule out aortic dissection, returned normal results. The pain subsided after two hours, but troponin kept increasing; consequently, spontaneous coronary artery dissection (SCAD) was suspected. In view of the young age of the patient, it was decided to refrain from performing a coronary angiogram, intravascular ultrasound, or optical coherence tomography. A CT coronary angiography scan did not show any anomaly. A cardiac magnetic resonance imaging showed a clear subendocardial enhancement indicative of a myocardial infarction. A diagnosis of SCAD was confirmed, and no further testing was done. The patient was started on aspirin and beta-blockers, and advised to perform only minimal to moderate exercise and to consult a healthcare physician immediately if the episode recurs. CT angiogram ruled out fibrodysplasia of the renal arteries, and plasma metanephrines were normal. This case shows that with the advancement of noninvasive techniques, there is probably no need for invasive measures to diagnose SCAD in stable patients.

Spontaneous Coronary Dissection Review: A Complex Picture

Spontaneous coronary artery dissection (SCAD) represents a quite rare event but with potentially serious prognostic implications. Meanwhile, SCAD typically presents as an acute coronary syndrome (ACS). Despite the majority of SCAD presentation being characterized by typical ACS signs and symptoms, young age at presentation with an atypical atherosclerotic risk factor profile is responsible for late medical contact and misdiagnosis. The diagnostic algorithm is similar to that for ACS. Low-risk factors prevalence and young age would push toward non-invasive imaging (such as coronary computed tomography (CT)); instead, the gold standard diagnostic exam for SCAD is an invasive coronary angiography (ICA) due to its increased sensitivity and disease characterization. Moreover, intravascular imaging (IVI) improves ICA diagnostic performance, confirming the diagnosis and clarifying the disease mechanism. A SCAD-ICA classification recognizes four angiographic appearances according to lesion extension and features (radiolucent lumen, long and diffuse narrowing, focal stenosis, and vessel occlusion). Concerning its management, the preferred approach is conservative due to the high rates of spontaneous healing in the first months and the low rate of revascularization success (high complexity percutaneous coronary intervention (PCI) with dissection/hematoma extension risk). Revascularization is recommended in the presence of high-risk features (such as left main or multivessel involvement, hemodynamic instability, recurrent chest pain, or ST elevation). The first choice is PCI; coronary artery bypass graft (CABG) is considered only if PCI is not feasible or too hazardous according to the operators' and centers' experience. Medical therapy includes beta blockers in cases of ventricular dysfunction; however, no clear data are available about antiplatelet treatment because of the supposed risk of intramural hematoma enlargement. Furthermore, screening for extracardiac arthropathies or connective tissue diseases is recommended due to the hypothesized association with SCAD. Eventually, SCAD follow-up is important, considering the risk of SCAD recurrence. Considering the young age of patients with SCAD, subsequent care is essential (including psychological support, also for relatives) with the aim of safe and complete reintegration into a non-limited everyday life.

In-hospital and long-term clinical outcomes of spontaneous coronary artery dissection (SCAD): a meta-analysis of conservative versus revascularization approaches

BACKGROUND

The ideal treatment strategy for spontaneous coronary artery dissection (SCAD) remains unclear, with patients potentially treated with either conservative medical care or a revascularization approach.

METHODS

We performed a systematic review and meta-analysis adhering to PRISMA 2020 guidelines. Inclusion criteria involved studies with confirmed SCAD diagnosis, reporting initial management strategies, and original research with ≥ 10 participants. Random-effect models were applied for insignificant heterogeneity with significance at p ≤ 0.05. Sensitivity analysis and funnel plots assessed potential publication bias.

RESULTS

Our analysis found no significant differences in major adverse cardiac events (MACE) (OR = 0.61, p = 0.49), unstable angina pectoris (UAP) (OR = 1.04, p = 0.93), non-ST segment elevation myocardial infarction (NSTEMI) (OR = 1.16, p = 0.82), recurrent myocardial infarction (MI) (OR = 0.78, p = 0.56), stroke (OR = 0.35, p = 0.07), heart failure (OR = 0.41, p = 0.24), in-hospital mortality (OR = 0.35, p = 0.09), post-discharge mortality (OR = 1.66, p = 0.27), or ST segment elevation myocardial infarction (STEMI) (OR = 0.45, p = 0.23) between conservative management and revascularization procedures. However, sensitivity analysis reveals significant decreases in odds of inferior wall STEMI (OR = 0.41 [95% CI 0.17-0.97], p = 0.04) and heart failure (OR = 0.18 [95% CI 0.06-0.54], p = 0.002) in conservative treatment compared to revascularization group.

CONCLUSION

Conservative therapy significantly decreased inferior wall STEMI and heart failure as compared to revascularization in SCAD. Although no significant differences in cardiovascular outcomes, sensitivity analysis highlights potential benefits of conservative management.

Spontaneous coronary artery dissection: review, case report and analysis of COVID-19-related cases

Spontaneous coronary artery dissection (SCAD) accounts for 1-4% of all acute coronary syndromes (ACS). Since the first description in 1931, our understanding of the disease has evolved; however, its pathophysiology and management are still a matter of debate. SCAD typically occurs in a middle-aged woman with no or few traditional cardiovascular risk factors. Two hypotheses have been proposed to explain the pathophysiology depending on the primary event: an intimal tear in the "inside-out" hypothesis and a spontaneous hemorrhage from the vasa vasorum in the "outside-in" hypothesis. Etiology appears to be multifactorial: different predisposing and precipitating factors have been identified. Coronary angiography is the gold standard for the diagnosis of SCAD. Current recommendations on the treatment of SCAD patients are based on expert opinions: a conservative strategy is preferred in hemodynamically stable SCAD patients, while urgent revascularization should be considered in hemodynamically unstable patients. Eleven cases of SCAD in COVID-19 patients have already been described: although the exact pathophysiological mechanism remains unclear, COVID-19-related SCAD is considered a combination of significant systemic inflammatory response and localized vascular inflammation. We present a literature review of SCAD, and we report an unpublished case of SCAD in a COVID-19 patient.

Spontaneous coronary artery dissection in patients with prior psychophysical stress: a systematic review of case reports and case series

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome, particularly in younger women. Due to limited information about SCAD, case reports and case series can provide valuable insights into its features and management. This study aimed to comprehensively evaluate the features of SCAD patients who experienced psychophysical stress before the SCAD event.

METHODS

We conducted an electronic search of PubMed, Scopus, and Web of Science from inception until January 7, 2023. We included case reports or series that described patients with SCAD who had experienced psychophysical stress before SCAD. Patients with pregnancy-associated SCAD were excluded from our analysis.

RESULTS

In total, we included 93 case reports or series describing 105 patients with SCAD. The average patient age was 44.29 ± 13.05 years and a total of 44 (41.9%) of patients were male. Among the included SCAD patients the most prevalent comorbidities were fibromuscular dysplasia (FMD) and hypertension with the prevalence of 36.4 and 21.9%, respectively. Preceding physical stress was more frequently reported in men than in women; 38 out of 44 (86.4%) men reported physical stress, while 36 out of 61 (59.1%) females reported physical stress (p value = 0.009). On the other hand, the opposite was true for emotional stress (men: 6 (13.6%)), women: 29 (47.6%), p value < 0.001). Coronary angiography was the main diagnostic tool. The most frequently involved artery was the left anterior descending (LAD) (62.9%). In our study, recurrence of SCAD due to either the progression of a previous lesion or new SCAD in another coronary location occurred more frequently in those treated conservatively, however the observed difference was not statistically significant (p value = 0.138).

CONCLUSION

While physical stress seems to precede SCAD in most cases, emotional stress is implicated in females more than males.

An Unusual Presentation of SCAD in a Young Male Soldier

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction and sudden cardiac death in young individuals without significant cardiovascular risk factors. The etiology of SCAD appears to be multifactorial and is often precipitated by physical and emotional stress superimposed on underlying arteriopathy, connective tissue disorders, systemic inflammatory disorders, genetic factors, and hormonal influences. There are no current societal guidelines to stratify young soldiers' risk of developing SCAD. Diagnosis typically requires invasive coronary artery angiography which is largely unavailable in stations with limited medical resources. Furthermore, young patients with SCAD often present with atypical cardiac symptoms, such as heartburn leading to the misdiagnosis of gastroesophageal reflux disease and a delay in diagnosis and management. We present a 21-year-old active duty male who was transferred from Okinawa, Japan to a tertiary military medical center for evaluation of hypercoagulable conditions after CT revealed non-obstructing portal venous thrombosis extending to right hepatic vein, splenic vein thrombosis with splenic infarct, and bilateral wedge-shaped renal infarct. Extensive work-up ultimately revealed mid-left anterior descending spiral dissection with transmural infarct of inferior, anteroseptal, and inferoseptal wall resulting in the formation of left ventricular thrombus, subsequently causing thromboembolism to multiple organs. This case demonstrates the ramifications of SCAD when diagnosis and management are delayed and serve as a poignant reminder for all providers to include SCAD in the differential diagnosis for young soldiers with atypical chest pain.

Spontaneous coronary artery dissection in women in the generative period: clinical characteristics, treatment, and outcome-a systematic review and meta-analysis

Introduction

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall.

Materials and methods

This systematic review and meta-analysis is reported following the PRISMA guidelines and is registered in the PROSPERO database. A literature search was focused on female patients in generative period (16-55 of age) with acute coronary syndrome (ACS) caused by SCAD, and comparison from that database NP-SCAD (spontaneous coronary artery dissection in non pregnant women) and P-SCAD (spontaneous coronary artery dissection in pregnant women).

Results

14 studies with 2,145 females in the generative period with ACS caused by SCAD were analyzed. The median age was 41 years (33.4-52.3 years). The most common risk factor was previous smoking history in 24.9% cases. The most common clinical presentation of ACS was STEMI in 47.4%. Conservative treatment was reported in 41.1%. PCI was performed in 32.7%, and 3.8% of patients had CABG surgery. LAD was the most frequently affected (50.5%). The prevalence of composite clinical outcomes including mortality, non-fatal MI and recurrent SCAD was 3.3% (95% CI: 1.4-5.1), 37.7% (95% CI: 1.9-73.4) and 15.2% (95% CI: 9.1-21.3) of patients. P-SCAD compared to NP-SCAD patients more frequently had STEMI (OR = 3.16; 95% CI: 2.30-4.34; I2 = 64%); with the left main and LAD more frequently affected [(OR = 14.34; 95% CI: 7.71-26.67; I2 = 54%) and (OR = 1.57; 95% CI: 1.06-2.32; I2 = 23%)]; P-SCAD patients more frequently underwent CABG surgery (OR = 6.29; 95% CI: 4.08-9.70; I2 = 0%). NP-SCAD compared to P-SCAD patients were more frequently treated conservatevly (OR = 0.61; 95% CI: 0.37-0.98; I2 = 0%). In P-SCAD compared to NP-SCAD mortality rates (OR = 1.13; 95% CI: 0.06-21.16; I2 = not applicable) and reccurence of coronary artery dissection (OR = 2.54; 95% CI: 0.97-6.61; I2 = 0%) were not more prevalent.

Conclusion

The results of this meta-analysis indicated that patients with P-SCAD more frequently had STEMI, and events more frequently involved left main and LAD compared to NP-SCAD patients. Women with NP-SCAD were significantly more often treated conservatively compared to P-SCAD patients. P-SCAD compared to NP-SCAD patients did not have significantly higher mortality rates or recurrent coronary dissection.

Update on sex specific risk factors in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.

Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature

Background

Contemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy.

Methods

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke.

Results

The systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/- 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3-75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%.

Conclusion

Our results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

Twenty-five-year trends in incidence, angiographic appearance, and management of spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) has been described as an infrequent cause of acute coronary syndrome (ACS). Knowledge about the disease is still limited and SCAD might still be underdiagnosed.

OBJECTIVES

Trends in incidence, presentation, angiographic appearance, management, and outcomes of SCAD over 25 years were analyzed.

METHODS

Patients with SCAD between 1997 and 2021 at the University Hospital Zurich, Switzerland, were included. Incidences were assessed as total numbers and proportions of ACS cases. Clinical data were collected from medical records and angiographic findings were reviewed. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, cardiac arrest, SCAD recurrence or progression, other myocardial infarction, and stroke.

RESULTS

One hundred fifty-six SCAD cases were included in this study. The incidence increased significantly in total (p < 0.001) and relative to ACS cases (p < 0.001). This was based on an increase of shorter lesions (p = 0.004), SCAD type 2 (p < 0.001), and lesions in side branches (p = 0.014), whereas lesions in the left main coronary artery and proximal segments were decreasing (p-values 0.029 and < 0.001, respectively). There was an increase in conservative therapy (p < 0.001). The rate of MACE (24%) was stable, however, there was a reduced proportion of patients with a need for intensive care treatment (p = 0.017).

CONCLUSIONS

SCAD represents an important entity of ACS that still might be underappreciated. The increasing incidence of SCAD is likely based on better awareness and familiarity with the disease. A lower need for intensive care treatment suggests positive effects of the increasing implementation of conservative management.

Regional and temporal variations of spontaneous coronary artery dissection care according to consensus recommendations: a systematic review and meta-analysis

AIM

The first expert consensus documents on management of patients with spontaneous coronary artery dissection (SCAD) were published in 2018. Worldwide quality of care, as measured by adherence to these recommendations, has not been systematically reviewed. We aim to review the proportion of patients with SCAD receiving consensus recommendations globally, regionally and, determine differences in practice before and after 2018.

METHODS AND RESULTS

A systematic review was performed by searching four main databases (Medline, Embase, SCOPUS, CINAHL) from their inception to 16 June 2022. Studies were selected if they included patients with SCAD and reported at least one of the consensus document recommendations. 53 studies, n=8456 patients (mean 50.1 years, 90.6% female) were included. On random effects meta-analysis, 92.1% (95% CI 89.3 to 94.8) received at least one antiplatelet, 78.0% (CI 73.5 to 82.4) received beta-blockers, 58.7% (CI 52.3 to 65.1) received ACE inhibitors or aldosterone receptor blockers (ACEIs/ARBs), 54.4% (CI 45.4 to 63.5) were screened for fibromuscular dysplasia (FMD), and 70.2% (CI 60.8 to 79.5) were referred to cardiac rehabilitation. Except for cardiac rehabilitation referral and use of ACEIs/ARBs, there was significant heterogeneity in all other quality-of-care parameters, across geographical regions. No significant difference was observed in adherence to recommendations in studies published before and after 2018, except for lower cardiac rehabilitation referrals after 2018 (test of heterogeneity, p=0.012).

CONCLUSION

There are significant variations globally in the management of patients with SCAD, particularly in FMD screening. Raising awareness about consensus recommendations and further prospective evidence about their effect on outcomes may help improve the quality of care for these patients.

Meta-regression analysis on the impact of medical therapy on long-term outcome in spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a relatively rare condition affecting predominantly young adults, with a prevalence of female sex. The best management of SCAD is still unclear and not adequately evidence-based both in the acute phase but especially over the long-term. We therefore aimed to evaluate the impact of medical therapy usually adopted for coronary artery disease on long-term outcome in SCAD patients.

METHODS

We performed a meta-regression analysis including all the studies evaluating the long-term outcome of patients affected by SCAD. We used long-term mortality, recurrent SCAD, admission for angina and major adverse cardio-vascular events (MACE) as dependent variables and the rates of discharge drug rates (beta-blockers, statins, renin-angiotensin-aldosterone system inhibitors, aspirin, dual antiplatelet therapy (DAPT)) as independent variables.

RESULTS

Fourteen observational studies were included with a long-term follow-up of 3.5 ± 1.7 years. No statistically significant correlations between drug therapy (beta-blockers, statins, calcium channel blockers, nitrates, renin-angiotensin-aldosterone inhibitors) and mortality, MACE, admission for angina, and SCAD recurrence were found. Higher aspirin use rates were significantly correlated with lower admission rates for angina (p < 0.05); DAPT, however, showed a borderline correlation with higher rates of SCAD recurrence (p = 0.068).

CONCLUSIONS

In a meta-regression analysis including observational studies aspirin use rates correlated with lower long-term rates of admission for angina, while a borderline correlation between DAPT and rates of SCAD recurrence was found. Other drugs usually used for the treatment of coronary artery disease do not seem to impact long-term outcome of SCAD patients.

Machine Learning in Invasive and Noninvasive Coronary Angiography

PURPOSE OF REVIEW

The objective of this review is to shed light on the transformative potential of machine learning (ML) in coronary angiography. We aim to understand existing developments in using ML for coronary angiography and discuss broader implications for the future of coronary angiography and cardiovascular medicine.

RECENT FINDINGS

The developments in invasive and noninvasive imaging have revolutionized diagnosis and treatment of coronary artery disease (CAD). However, CAD remains underdiagnosed and undertreated. ML has emerged as a powerful tool to further improve image analysis, hemodynamic assessment, lesion detection, and predictive modeling. These advancements have enabled more accurate identification of CAD, streamlined workflows, reduced the need for invasive diagnostic procedures, and improved the diagnostic value of invasive procedures when they are needed. Further integration of ML with coronary angiography will advance the prevention, diagnosis, and treatment of CAD. The integration of ML with coronary angiography is ushering in a new era in cardiovascular medicine. We highlight five use cases to leverage ML in coronary angiography: (1) improvement of quality and efficacy, (2) characterization of plaque, (3) hemodynamic assessment, (4) prediction of future outcomes, and (5) diagnosis of non-atherosclerotic coronary disease.

Spontaneous coronary artery dissection: an overview

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

An analysis of published cases of cutting balloon use in spontaneous coronary artery dissection

Introduction

SCAD involves a sudden tear or separation within the layers of the coronary artery wall, resulting in blood flow obstruction and subsequent myocardial ischemia.

Materials and methods

A comprehensive literature search was conducted to identify relevant published cases of cutting balloon use in patients diagnosed with spontaneous coronary artery dissection. Electronic databases including PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar were systematically searched from inception until the present using terms "cutting balloon," "SCAD," "acute coronary syndrome," "intramural hematoma," and "angioplasty."

Results

A total of 32 published cases of cutting balloon use in spontaneous coronary artery dissection were analyzed in this study. The majority of the patients included in the analysis were female without prior history of cardiovascular disease. The median age of the SCAD population was approximately 46 years. The most frequently affected artery in SCAD cases was the Left Anterior Descending artery. Intravascular ultrasound was utilized more frequently than other modalities of adjunctive imaging techniques. The most frequent complication was the distal propagation of hematoma. Despite the successful dilation achieved with the cutting balloon, in some cases stenting was required to provide additional support.

Conclusion

The results of this analysis demonstrate that cutting balloon use in SCAD cases yields favorable outcomes.

Primary Percutaneous Coronary Intervention in Patients With Spontaneous Coronary Artery Dissection vs Coronary Artery Disease

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction. Revascularization in SCAD remains very challenging and therefore is not recommended as the initial management strategy in stable SCAD without high-risk features.

OBJECTIVES

The aim of this study was to compare in-hospital mortality and 30-day readmission rates between patients with SCAD with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) and patients with STEMI without SCAD undergoing PPCI.

METHODS

This study was conducted using the administrative minimum dataset of the Spanish National Health System (2016-2020). Risk-standardized in-hospital mortality ratios and readmission ratios were calculated, and results were adjusted using propensity score (PS) analyses.

RESULTS

A total of 65,957 episodes of PPCI were identified after exclusions. The crude in-hospital mortality rate was 4.8%. Of these, 315 (0.5%) were SCAD PPCI and 65,642 were non-SCAD PPCI. SCAD PPCI patients were younger and more frequently women than non-SCAD PPCI patients. Crude mortality (5.7% vs 4.8%), risk-standardized in-hospital mortality ratio (5.3% vs 5.3%), and PS-adjusted (315 pairs) mortality (5.7% vs 5.7%) were similar in SCAD PPCI and non-SCAD PPCI patients. In addition, crude (3% vs 3.3%) and PS-adjusted (297 pairs) 30-day readmission rates (3% vs 4%) were also similar in both groups.

CONCLUSIONS

PPCI, when indicated in patients with STEMI and SCAD, has similar in-hospital mortality and 30-day readmission rates compared with PPCI for atherothrombotic STEMI. These findings support the value of PPCI in selected patients with SCAD.

Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

Spontaneous coronary artery dissection: the emerging role of coronary computed tomography

Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome and myocardial infarction, more frequent among young women. Invasive coronary angiography (ICA) is the gold standard for the diagnosis of SCAD, although the risk of propagating dissection flap is considerable. Therefore, coronary computed tomography angiography (CCTA) is an emerging alternative modality to diagnose SCAD with the advantage of being a non-invasive technique. Clinicians should be aware of the predisposing conditions and pathophysiology to raise the pre-test probability of SCAD and select the most appropriate diagnostic tools. In recent times, improvements in spatial and temporal resolution and the use of semi-automated software providing quantitative assessment make CCTA a valid alternative to ICA also for the follow-up. Moreover, CCTA may be helpful to screen and evaluate extra-coronary arteriopathies closely related to SCAD. In this review, we illustrate the current and the potential role of CCTA in the diagnosis of SCAD, highlighting advantages and disadvantages of this imaging modality compared to ICA.

Multimodality Imaging Approach to Spontaneous Coronary Artery Dissection

Spontaneous Coronary Artery Dissection (SCAD) refers to the spontaneous separation of the layers of the vessel wall caused by intramural hemorrhage, with or without an intimal tear. The "typical" SCAD patient is a middle-aged woman with few traditional cardiovascular risk factors, and it's frequently associated with pregnancy. Because of its low incidence, its pathophysiology is not fully understood. SCAD presents as an acute coronary syndrome, with chest pain, dyspnea, syncope, or heartbeat, even if diagnosis and clinical handling are different: coronary angiography is currently the main tool to diagnose SCAD; however, in doubtful cases, the use of both invasive and noninvasive cardiovascular imaging methods such as intravascular ultrasound or optical coherence tomography may be necessary. This paper aims to review the current state of knowledge on SCAD to address its demographic features, clinical characteristics, management, and outcomes, focusing on diagnostic algorithms and main multimodality imaging techniques.

Spontaneous coronary artery dissection: an uncommon primary presenting feature of fibromuscular dysplasia

Spontaneous coronary artery dissection is a rare but increasingly recognised cause of acute coronary syndrome particularly in young women, accounting for up to 25% of acute coronary syndrome cases in women under 50. It is, however, an uncommon primary presenting pathology of underlying fibromuscular dysplasia. We present the case of a woman in her 40s, with no significant medical history, presenting with anterior ST elevation myocardial infarction, identified as spontaneous coronary artery dissection on invasive coronary angiogram with an underlying aetiology, and subsequent diagnosis, of fibromuscular dysplasia being established on MR angiography.

Characteristics and outcomes of percutaneous coronary interventions in patients with spontaneous coronary artery dissection. A study from the administrative minimum data set of the Spanish National Health System

BACKGROUND

Coronary revascularization in patients with spontaneous coronary artery dissection (SCAD) is challenging. Indications and results of percutaneous coronary interventions (PCI) in SCAD patients are not well established.

AIM

To assess indications and results of PCI in SCAD.

METHODS

The minimum basic data set of the Spanish National Health System (years 2016-2019) was used to identify 804 episodes of acute myocardial infarction (AMI) and SCAD, with a crude in-hospital mortality rate of 3%. Of these, 368 (46.8%) patients were revascularized with PCI during admission whereas 436 (54.2%) were managed conservatively.

RESULTS

Revascularization and in-hospital mortality rates both declined over the study period (p for trend both < 0.05). SCAD patients treated with PCI were older, more frequently male, and had higher frequency of diabetes, ST-segment elevation AMI and cardiogenic shock, compared to patients managed conservatively. The crude in-hospital mortality rate was higher in patients treated with PCI (4.9% vs. 1.4%; p = 0.004). However, after adjusting by propensity score (223 pairs) the in-hospital mortality rate was similar in the two groups (Adj OR: 1.21; 95%CI: 0.30-1.57; p = 0.76). Readmissions at 30-days were higher in patients managed conservatively (7.1 vs. 1.6%, p < 0.001) and this difference was maintained after propensity score adjustment (Adj average treatment effect: 2% vs. 12.2%; OR: 0.15; 95%CI: 0.04-0.45; p < 0.001).

CONCLUSION

Revascularization is frequently used in unselected patients with AMI and SCAD but its use is declining. Patients with SCAD treated with PCI have a higher in-hospital mortality but this appears to be explained by their adverse baseline clinical characteristics.

Revascularization and long-term outcomes in high-acuity spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is often treated conservatively due to revascularization risks. Yet, an important number of SCAD patients have high acuity characteristics necessitating revascularization, with uncertain long-term outcomes.

OBJECTIVES

Document revascularization utilization and long-term outcomes in high acuity SCAD.

METHODS

Prospective/retrospective analysis of consecutive patients with acute myocardial infarction (AMI) due to first SCAD event presenting directly to the Minneapolis Heart Institute 2002-2021, median follow-up 3.8 years.

RESULTS

Among 139 patients (age 49 ± 12 years, 96% female), revascularization was performed in 60 (43%), utilizing percutaneous coronary intervention (PCI) (n = 56, successful in 80%) or coronary artery bypass graft (n = 4). In the entire cohort, 90 (65%) unique patients had one or more high acuity characteristic: ST-elevation (38%), proximal dissection (38%), cardiogenic shock (6.5%), cardiac arrest (9.4%), left main dissection (6.5%), peripartum dissection (7.2%). High acuity patients accounted for 51 of 60 (85%) revascularizations. Revascularization rates were: ST-elevation (60%), proximal dissection (62%), cardiogenic shock (89%), cardiac arrest (62%), left main dissection (100%), peripartum dissection (70%). Survival was 97% (revascularized) vs 100% (nonrevascularized); p = 0.2. Adverse outcomes (revascularized vs. nonrevascularized) included recurrent AMI:16.7% versus 8.9%; p = 0.2, SCAD recurrence: 13.3% versus 6.3%; p = 0.1, stroke: 5% versus 2.5%; p = 0.44, implantable cardioverter-defibrillator: 6.7% versus 6.3%; p > 0.9. Reintervention was necessary in 21% of PCI-treated patients.

CONCLUSIONS

High-acuity characteristics were present in nearly two-thirds of this SCAD cohort; the vast majority of revascularizations were performed in high-acuity patients. Despite high acuity, long-term survival was favorable in revascularized patients.

Spontaneous coronary artery dissection in Spain: a study using the minimum data set of the Spanish National Health System

INTRODUCTION AND OBJECTIVES

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). We sought to compare the results on in-hospital mortality and 30-day readmission rates among patients with AMI-SCAD vs AMI due to other causes (AMI-non-SCAD).

METHODS

Risk-standardized in-hospital mortality (rIMR) and risk-standardized 30-day readmission ratios (rRAR) were calculated using the minimum dataset of the Spanish National Health System (2016-2019).

RESULTS

A total of 806 episodes of AMI-SCAD were compared with 119 425 episodes of AMI-non-SCAD. Patients with AMI-SCAD were younger and more frequently female than those with AMI-non-SCAD. Crude in-hospital mortality was lower (3% vs 7.6%; P<.001) and rIMR higher (7.6±1.7% vs 7.4±1.7%; P=.019) in AMI-SCAD. However, after propensity score adjustment (806 pairs), the mortality rate was similar in the 2 groups (AdjOR, 1.15; 95%CI, 0.61-2,2; P=.653). Crude 30-day readmission rates were also similar in the 2 groups (4.6% vs 5%, P=.67) whereas rRAR were lower (4.7±1% vs 4.8%±1%; P=.015) in patients with AMI-SCAD. Again, after propensity score adjustment (715 pairs) readmission rates were similar in the 2 groups (AdjOR, 1.14; 95%CI, 0.67-1.98; P=.603).

CONCLUSIONS

In-hospital mortality and readmission rates are similar in patients with AMI-SCAD and AMI-non-SCAD when adjusted for the differences in baseline characteristics. These findings underscore the need to optimize the management, treatment, and clinical follow-up of patients with SCAD.

Spontaneous coronary artery dissection: A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic, non-traumatic separation of the coronary artery wall. The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors. SCAD is frequently linked with predisposing factors, such as postpartum, fibromuscular dysplasia or other vasculopathies, connective tissue disease and hormonal therapy, and it is often triggered by intense physical or emotional stress, sympathomimetic drugs, childbirth and activities increasing shear stress of the coronary artery walls. Patients with SCAD usually present at the emergency department with chest discomfort, chest pain, and rapid heartbeat or fluttery. During the last decades, the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis. However, modern imaging techniques such as optical coherence tomography, intravascular ultrasound, coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease. Treatment of SCAD remains controversial, especially during the last years, where invasive techniques are being used more often and in more emergent cardiac syndromes. Although conservative treatment combining aspirin and beta-blocker remains the recommended strategy in most cases, revascularization could also be suggested as a method of treatment in specific indications, but with a higher risk of complications. The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients. Follow-up should be performed on a regular basis.

Differences in Demographics and Outcomes Between Men and Women With Spontaneous Coronary Artery Dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction (MI) that most frequently affects women. The characteristics of men with SCAD are less well described.

OBJECTIVES

The aim of this study was to describe the characteristics of men with SCAD.

METHODS

We compared baseline demographics, clinical presentation, angiographic findings and cardiovascular outcomes of men and women in the Canadian SCAD Study. Major adverse cardiovascular events (MACE) were composite of death, MI, stroke or transient ischemic attack, heart failure hospitalization, and revascularization.

RESULTS

Of 1,173 patients with SCAD, 123 (10.5%) were men. Men with SCAD were younger than women (mean age 49.4 ± 9.6 years vs 52.0 ± 10.6 years; P = 0.01). Men had lower rate of prior MI than women (0.8% vs 7.0%; P = 0.005). Men were less likely to have fibromuscular dysplasia (FMD) (27.8% vs 52.7%; P = 0.001), depression (9.8% vs 20.2%; P = 0.005), emotional stress (35.0% vs 59.3%; P < 0.001), or high score on the Perceived Stress Scale (3.5% vs 11.0%; P = 0.025) but were more likely to report isometric physical stress (40.2% vs 24.0%; P = 0.007). There was no difference in angiographic types of SCAD, but men had more circumflex artery (44.4% vs 30.9%; P = 0.001) and fewer right coronary artery (11.8% vs 21.7%; P = 0.0054) dissections. At median follow-up of 3.0 (IQR: 2.0-3.8) years, men had fewer hospital presentations with chest pain (10.6% vs 24.8%; P < 0.001). There were no differences in in-hospital events or follow-up MACE (7.3% vs 12.7%; P = 0.106).

CONCLUSIONS

Ten percent of SCAD patients were men. Men were younger and more likely to have a physical trigger but were less likely to have FMD, depression, or an emotional trigger. Men had less recurrent chest pain but no significant difference in MACE.

Cardiovascular disease in women: A review of spontaneous coronary artery dissection

Research has demonstrated the disproportionate quality of care for women with cardiovascular disease. These findings have prompted a renewed focus on cardiovascular disease awareness and disease prevention in women. Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and sudden death that primarily affects women. ongoing research has led to improved diagnostic capabilities and changes in approaches to initial and long-term management most importantly this research has provided evidence that SCAD is more common than previously thought and must be evaluated and treated differently from atherosclerotic MI. The difference between SCAD and atherosclerotic MI is highlighted in high rates of recurrent disease, gender distribution, association with exogenous hormones, pregnancy, migraine, physical and emotional stress triggers, concurrent systemic arteriopathies, and connective tissue disease. In this review, we provide updated insights and a summary of the epidemiology, risk factors, clinical presentation, diagnosis, treatment options, prognosis, and recurrence prevention of SCAD. We aim to provide a review of SCAD as a focus on cardiovascular disease awareness and disease prevention in women.

Nationwide observational study of incidence, management and outcome of spontaneous coronary artery dissection: a report from the Swedish Coronary Angiography and Angioplasty register

OBJECTIVES

The aim of this study was to conduct a nationwide all comer description of incidence, contemporary management and outcome in Swedish spontaneous coronary artery dissection (SCAD) patients. The incidence of SCAD as well as the management and outcome of these patients is not well described.

DESIGN

A nationwide observational study.

PARTICIPANTS AND SETTING

All patients with SCAD registered in the Swedish Coronary Angiography and Angioplasty Register from 2015 to 2017 were included. The index angiographies of patients with registered SCAD were re-evaluated at each centre to confirm the diagnosis. Patients with non-SCAD myocardial infarction (MI) (n=32 601) were used for comparison.

OUTCOME MEASURES

Outcomes included all-cause mortality, reinfarction or acute coronary reangiography.

RESULTS

This study found 147 SCAD patients, rendering an incidence of 0.74 per 100 000 per year and a prevalence of 0.43% of all MIs. The average age was 52.9 years, 75.5% were women and 47.6% presented with ST-segment elevation MI. Median follow-up time for major adverse cardiac event was 17.3 months. Percutaneous coronary intervention was attempted in 40.1% of SCAD patients and 30.6% received stent. The use of antithrombotic agents was similar between the groups and there was no difference regarding outcomes, 10.9% vs 13.4%, p=0.75. Mortality was lower in SCAD patients, 2.7% vs 8.0%, p=0.03, whereas SCAD patients more often underwent acute reangiography, 9.5% vs 4.6%, p<0.01.

CONCLUSION

In this nationwide, all comer Swedish study, the overall incidence of SCAD was low, including 25% men which is more and in contrast to previous studies. Compared with non-SCAD MI, SCAD patients were younger, with lower cardiovascular risk burden, yet suffered substantial mortality and morbidity and more frequently underwent acute coronary reangiography.

Spontaneous Coronary Artery Dissection and Its Management: A Case Report

We illustrate a notable case of an elderly male presenting to a community hospital with six out of 10 substernal chest discomfort and electrocardiogram changes consistent with an anterolateral myocardial infarction. Percutaneous Coronary Intervention (PCI) was initiated following aspirin and anticoagulation administration, which further revealed a critical distal left main spontaneous coronary artery dissection (SCAD). Cardiothoracic and Vascular Surgery consults led to the recommendation of emergent two-vessel Coronary Artery Bypass Grafting (CABG). The patient’s clinical status resolved to full recovery and was discharged on postoperative day five. The incidence of SCAD in older men has not been well documented in current literature. Prevalence in older males is 0.02%. However, it rises to 10.8% in females less than 50 years of age and with acute coronary syndromes (ACS) and ST-segment elevation. Our aim is to incorporate this case report into the current literature and help improve early diagnosis and treatment based on current recommendations.

Sex Related Differences in the Treatment of ST-Segment Elevation Acute Myocardial Infarction in Patients Aged <55 years

Gender-related differences after ST-segment elevation myocardial infarction (STEMI) have been reported, but studies have generally focused on high-risk groups and results are inconsistent. This study aims to determine gender-related differences in the treatment of STEMI and in-hospital mortality in a contemporary cohort of young patients. We included patients aged <55 years admitted to the Acute Cardiac Care Unit with STEMI during an 11-year period. We retrospectively reviewed the clinical charts to register information on demographics, clinical and laboratory data, angiography, treatment received, complications, and in-hospital mortality. A total of 812 patients were included (712 men and 100 women). There were no gender-related differences in age or prevalence of cardiovascular risk factors. Women, as compared with men, had higher incidence of nonobstructive angiography (14.0% vs 2.4%) and coronary tortuosity (4.0% vs 0.8%), and lower incidence of multivessel disease (35.0% vs 49.6%) (p <0.05). Less frequently than men, women received percutaneous transluminal coronary angioplasty (94.0% vs 98.2%), and stent placement (82.0% vs 93.8%), inotropic agents (2.0% vs 8.3%), hypothermia after cardiac arrest (25.0% vs 84.0%), and mechanical ventilation (4.0% vs 11.0%) (p <0.05). These differences were not explained by the different angiographic findings. In-hospital mortality was 2.0% and 3.4%, in women and men, respectively (adjusted odds ratio 0.712, 95% confidence interval 0.164 to 3.093, p = 0.650). In conclusion, women aged <55 years with STEMI were held to different treatment standards than men.

The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population

OBJECTIVES

Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners.

METHODS

Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics.

RESULTS

Of 1196 subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients.

CONCLUSION

With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.

Snake in right coronary artery-Extensive spontaneous coronary artery dissection in a young male

We report an interesting case of a young man who revealed extensive spontaneous dissection of the RCA in diagnostic angiography. It was surprising that despite an extensive dissection, the patient remained hemodynamically stable on medical management throughout the procedure and during the post-procedure hospital stay.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.

Factors Associated With Revascularization in Women With Spontaneous Coronary Artery Dissection and Acute Myocardial Infarction

In contrast to atherosclerotic acute myocardial infarction (AMI), conservative therapy is considered preferable in the acute management of spontaneous coronary artery dissection (SCAD) if clinically possible. The present study aimed to investigate factors associated with treatment strategy for SCAD. Women aged ≤60 years with AMI and SCAD were retrospectively identified in the Nationwide Readmissions Database 2010 to 2015 and were divided into revascularization and conservative therapy groups. The revascularization group (n = 1,273, 68.0%), compared with the conservative therapy group (n = 600, 32.0%), had ST-elevation AMI (STEMI) (anterior STEMI, 20.3% vs 10.5%; inferior STEMI, 25.1% vs 14.5%; p <0.001) and cardiogenic shock (10.8% vs 1.8%; p <0.001) more frequently. Multivariable logistic regression analysis demonstrated that anterior STEMI (vs non-STEMI, odds ratio 2.89 [95% confidence interval 2.08 to 4.00]), inferior STEMI (2.44 [1.85 to 3.21]), and cardiogenic shock (5.13 [2.68 to 9.80]) were strongly associated with revascularization. Other factors associated with revascularization were diabetes mellitus, dyslipidemia, smoking, renal failure, and pregnancy/delivery-related conditions; whereas known fibromuscular dysplasia and admission to teaching hospitals were associated with conservative therapy. Propensity-score matched analyses (546 pairs) found no significant difference in in-hospital death, 30-day readmission, and recurrent AMI between the groups. In conclusion, STEMI presentation, hemodynamic instability, co-morbidities, and setting of treating hospital may affect treatment strategy in women with AMI and SCAD. Further efforts are required to understand which patients benefit most from revascularization over conservative therapy in the setting of SCAD causing AMI.

Clinical implications of arterial hypertension in patients with spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome. Many patients with SCAD have associated coronary risk factors. However, the implications of arterial hypertension in SCAD patients remain unknown.

OBJECTIVE

This study sought to assess the clinical implications of arterial hypertension in a nationwide cohort of patients with SCAD.

METHODS

The Spanish SCAD registry (NCT03607981) prospectively enrolled 318 consecutive patients. All coronary angiograms were centrally analyzed to confirm the diagnosis of SCAD. Patients were classified according to the presence of arterial hypertension.

RESULTS

One-hundred eighteen patients (37%) had a diagnosis of arterial hypertension. Hypertensive SCAD patients were older (60 ± 12 vs. 51 ± 9 years old) and had more frequently dyslipidemia (56 vs. 23%) and diabetes (9 vs. 3%) but were less frequently smokers (15 vs. 35%) than normotensive SCAD patients (all P < 0.05). Most patients in both groups were female (90 vs. 87%, NS) and female patients with hypertension were more frequently postmenopausal (70 vs. 47%, P < 0.05). Hypertensive SCAD patients had more severe lesions and more frequently multivessel involvement (15 vs. 7%, P < 0.05) and coronary ectasia (19 vs. 7%, P < 0.05) but showed a similar prevalence of coronary tortuosity (34 vs. 26%, NS). Revascularization requirement was similar in both groups (17 vs. 26%, NS) but procedural success was significantly lower (65 vs. 88%, P < 0.05) and procedural-related complications more frequent (65 vs. 41%, P < 0.05) in SCAD patients with hypertension.

CONCLUSION

Patients with SCAD and hypertension are older, more frequently postmenopausal and have more coronary risk factors than normotensive SCAD patients. During revascularization SCAD patients with hypertension obtain poorer results and have a higher risk of procedural-related complications (NCT03607981).

Three-vessel spontaneous coronary artery dissection in a patient with hyperhomocysteinemia

Increased homocysteine has been related to the occurrence of dissections in the coronary circulation, aorta, and cervical arteries. Spontaneous coronary artery dissection (SCAD) is a relatively rare phenomenon, and data on the long-term follow-up of patients with SCAD are extremely limited. Herein, we describe a case of a young male patient with 3-vessel SCAD (presence of radiolucent linear defects indicating the presence of dissections in all three major coronary arteries) who was found to have hyperhomocysteinemia and a concurrent methylenetetrahydrofolate reductase prothrombotic mutation. Despite the presence of multi-vessel SCAD, the patient had clinically stable coronary artery disease for a long period. .

Spontaneous Coronary Artery Dissection: New Insights into This Not-So-Rare Condition

Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute myocardial infarction (MI) among young and middle-aged women and is an important cause of pregnancy-associated MI. Over 90% of SCAD patients are women. Compared to patients with MI caused by atherosclerosis, SCAD patients have fewer cardiovascular risk factors but more often have systemic arteriopathy, most commonly fibromuscular dysplasia. Angiographically, SCAD is characterized by the presence of an intramural hematoma with or without an intimal tear. Accurate recognition of characteristic findings on coronary angiography is critical, as there are important differences in the acute and long-term management of MI caused by SCAD versus atherosclerosis. Acutely, most SCAD patients should be managed conservatively, since percutaneous revascularization is associated with more complications and SCAD-affected vessels usually heal without intervention. Randomized clinical trials and other prospective evaluations are needed, especially to clarify optimal treatment and prevention strategies.