Spontaneous coronary artery dissection: an overview

Spontaneous coronary artery dissection in regions of non-Western populations: a systematic literature search and scoping review

Current data on spontaneous coronary artery dissection (SCAD) predominantly originate from Europe or Caucasians with limited information about other ethnicities. This scoping review presents the evidence on SCAD in non-Western countries. The prevalence of SCAD diagnosis was 1.0% [95% confidence interval (95% CI): 0.0-3.0, I 2 = 99%] among patients presenting with myocardial infarction, increasing to 5.0% (95% CI: 1.0-16.0, I 2 = 99%) among females. The mean age was 51.3 years with females accounting for 54.0% of patients. A conservative revascularization management was reported in 48.0% (95% CI: 32.0-65.0, I 2 = 85%) of patients. Antiplatelet therapy was reported as dual (68.0%, 95% CI: 37.0-89.0, I 2 = 90%) in only three studies. A death rate (3.0%) was similar during hospitalization and at mean follow-up of 23.42 months. In conclusion, there is a marked variability in the clinical course of patients with SCAD as well heterogeneity among the included studies. This review identified knowledge gaps in our understanding of SCAD in non-Western countries that should be addressed in future prospective 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.

Best Practices for Women with Spontaneous Coronary Artery Dissection Undergoing Invasive Coronary Angiography

Spontaneous coronary artery dissection (SCAD) is a pathophysiologically heterogenous, infrequent but high-risk cause of acute coronary syndrome in a young, unsuspecting population without traditional cardiovascular risk factors. Diagnosis requires a high index of clinical suspicion, knowledge of the angiographic features of SCAD, and comfort with using the necessary ancillary diagnostic tools. Although most of the patients are medically managed, a small percentage do require revascularization. Knowing the high risk of complications and failure rate associated with SCAD percutaneous coronary intervention, interventional cardiologists should familiarize themselves with the recommended strategies and best practices to maximize success and improve patient outcomes.

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.

Characteristics of Patients with Spontaneous Coronary Artery Dissection Presenting with Sudden Cardiac Arrest in the United States and the Potential Role of Implantable Cardioverter Defibrillator Therapy

Background

Spontaneous coronary artery dissection (SCAD) is a disease entity that often occurs in young, healthy women and can cause life-threatening ventricular arrhythmias and sudden cardiac arrest. However, the characteristics and outcomes of SCAD with cardiac arrest are not well characterized.

Methods

This study investigated the baseline characteristics of SCAD patients with cardiac arrest using the National Inpatient Sample (NIS) database between 2016 and 2020. In addition, we also sought to determine the potential impact that implantable cardioverter defibrillator (ICD) therapy had on morbidity and mortality in SCAD patients presenting with cardiac arrest.

Results

Our findings showed that the SCAD with cardiac arrest population had significantly higher comorbidities, including cardiac arrhythmias, congestive heart failure, pulmonary circulation disorders, liver diseases, solid tumors, coagulopathy, fluid disorders, chronic kidney disease (CKD), anemia secondary to deficiency, psychosis, neurological disorders, carotid artery disease, atrial fibrillation, ventricular arrhythmias (ventricular tachycardia (VT), ventricular fibrillation (VF)), and acute myocardial infarction (AMI), compared to the SCAD without cardiac arrest population. Likewise, for SCAD patients who did not have an ICD in place, we found increasing age, fluid and electrolyte disorders, uncomplicated diabetes, neurological disorders, peripheral vascular disease, pulmonary circulatory disorders, cardiac arrhythmias, and congestive heart failure to be associated with greater mortality.

Conclusions

SCAD patients with certain comorbidities (e.g., pulmonary diseases, liver diseases, cancers, coagulopathy, and CKD) who presented with AMI or congestive heart failure should be monitored closely for ventricular arrhythmias as they have a higher chance of progressing to cardiac arrest. ICD therapy can be considered for these patients, but data on the success of this treatment option are limited, and more research needs to be performed to determine whether the benefits of this outweigh the risks.

The Spectrum of Coronary Artery Disease in Elite Endurance Athletes-A Long-Standing Debate: State-of-the-Art Review

Physical activity is recommended for the prevention of primary and secondary cardiovascular (CV) disease as it is linked to a number of health benefits, especially CV. However, recent research suggests that high-volume, long-term endurance exercise may hasten rather than slow the coronary atherosclerosis progression. This contentious theory has generated a great discussion and is still a major source of doubt when it comes to the clinical treatment of coronary artery disease (CAD) in athletes. CAD is the primary cause of sudden cardiac death in athletes over 35 years. Thus, recent studies evaluated the prevalence of CAD in athletes and its clinical and prognostic implications. Indeed, many studies have shown a relationship between endurance sports and higher volumes of coronary calcified plaque as determined by computed tomography. However, the precise pathogenetic substrate for the existence of an increased coronary calcification burden among endurance athletes remains unclear. Moreover, the idea that coronary plaques in elite athletes present a benign morphology has been cast into doubt by some recent studies showing potential association with adverse cardiovascular events. This review aims to analyze the association between physical activity and CAD, explaining possible underlying mechanisms of atherosclerotic progression and non-ischemic coronary lesions, focusing primarily on clinical and prognostic implications, multimodal evaluation, and management of CAD in endurance athletes.

Spontaneous Coronary Artery Dissection in Clinical Practice: Pathophysiology and Therapeutic Approaches

Spontaneous coronary artery dissection (SCAD) is a cause of myocardial infarction without obstructive coronary artery disease (MINOCA). It is determined by a coronary artery wall layers separation, which occurs regardless of traumatic or iatrogenic injuries. Even if it is often a missed diagnosis, its incidence is growing along with the improvement of intracoronary imaging techniques that allow for better detection. The main angiographical classification distinguishes three different forms, with slightly different prognoses at long-term follow up. SCAD is a recurrent condition, severely hampering the life quality of affected patients. The predominantly young age of patients with SCAD and the high prevalence of females among them have made the topic increasingly important, especially regarding therapeutic strategies. According to the data, the most recommended treatment is conservative, based on the use of antiplatelet agents and supportive anti-ischemic therapy. However, there are conflicting opinions concerning the need for dual antiplatelet therapy and its duration. In the case of invasive treatment, the choice between percutaneous coronary intervention and coronary artery bypass graft depends on the patient's clinical stability and the interested vessel. The purpose of the current review is to revise the pathophysiological mechanisms underlying SCAD and the current knowledge of its treatment.