Spontaneous Coronary Artery Dissection in Men

Sex differences in secondary prevention needs and recommendations among patients with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as a cause of heart attacks, particularly for female patients; however, ∼10% of cases occur in male patients. While male and female differences pertaining to clinical outcomes and treatment protocols have been addressed in the literature, research is limited on sex differences in secondary prevention programming, such as cardiac rehabilitation. Cardiac rehabilitation is recommended for patients with SCAD to promote physical and mental recovery. This letter highlights sex-specific gaps in existing programming and reports patients' suggestions for enhancing the recovery of this unique patient population.

The 2024 US Medical Eligibility Criteria for Contraceptive Use: Application to Practice in the Care of Patients With Cardiac Disease

Cardiovascular disease is the leading cause of maternal mortality in the United States, with the majority of deaths stemming from preventable causes. Contraception is one of the tools that can be utilized to prevent mortality and morbidity associated with unplanned pregnancy in patients with underlying congenital or acquired heart disease. There are a wide range of contraceptive methods available. While some methods, especially those containing estrogen, may be associated with increased risks in certain cardiac disease states, intrauterine devices, implants, and progestin-only methods may be safely used by the vast majority of patients with cardiac disease. Furthermore, intrauterine devices and implants are the most effective reversible contraceptive methods available. This review provides a summary of the US Centers for Disease Control and Prevention 2024 Medical Eligibility Criteria for Contraceptive Use as it applies to cardiac disease states. This review emphasizes the importance of contraceptive counseling and aims to familiarize the reader with the various forms of contraception available to patients, as well as the risks and benefits of each method in patients with different types of cardiac disease.

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.

Sex and Gender Differences in Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disease that was once underrecognized and is significantly more prevalent in women than men. Although it most commonly affects the renal and extracranial carotid arteries, FMD can affect any vascular bed. Complications of FMD can include hypertension, dissection, and stroke. Presentation may vary between the sexes, with male patients having an increased frequency of arterial dissection and aneurysms compared with female patients. Diagnosis requires a high index of suspicion by the treating physician. Several imaging studies can assist with diagnosis, and treatment focuses on the monitoring of affected vessels and intervention only as needed. Antiplatelet therapy for prevention of thrombotic complications is recommended. Studies are still underway to examine the genetic underpinnings of FMD pathophysiology and to evaluate the underlying mechanism of this disease that affects more female than male patients.

Sex differences in patients presenting with acute coronary syndrome: a state-of-the-art review

Cardiovascular conditions in the spectrum of acute coronary syndromes are characterized by sex differences with regard to pathophysiology, risk factors, clinical presentation, invasive and pharmacologic treatment, and outcomes. This review delves into these differences, including specific subsets like myocardial infarction with non-obstructed coronary arteries or Spontaneous Coronary Artery Dissection, and alternative diagnoses like Takotsubo cardiomyopathy or myocarditis. Moreover, practical considerations are enclosed, on how a sex-specific approach should be integrated in clinical practice: in fact, personal history should focus on female-specific risk factors, and hormonal status and hormonal therapy should be assessed. Moreover, physical and psychological stressors should be investigated, particularly in the event of Spontaneous Coronary Artery Dissection or Takotsubo cardiomyopathy.

Sex and Gender Differences in Cardiovascular Disease: A Review of Spontaneous Coronary Artery Dissection

This review highlights sex- and gender-specific considerations in cardiovascular diseases with a particular focus on pathophysiology, epidemiology, clinical presentation, risk factors, diagnosis, and management of spontaneous coronary artery dissection. It aims to summarize the most up to date evidence and gaps in knowledge that exist in the spontaneous coronary artery dissection space while highlighting salient points with regards to sex- and gender-based differences in clinical implications, current management, and recommended counseling practices.

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.