Spontaneous coronary artery dissection (SCAD): new insights into this not-so-rare condition

Healthcare Disparities in Cardiovascular Medicine

There are significant healthcare disparities in cardiovascular medicine that represent a challenge for cardiologists and healthcare policy-makers who wish to provide equitable care. Disparities exist in both the management and outcomes of hypertension, coronary artery disease and its sequelae, and heart failure. These disparities are present along the lines of race, gender, and socioeconomic status. Despite recent efforts to reduce disparity, there are knowledge and research gaps among cardiologists with regards to both the scope of the problem and how to solve it. Solutions include increasing awareness of disparities in cardiovascular health, increasing research for optimal treatment of underserved communities, and public policy changes that reduce disparities in social determinants of health.

Social Media and Cardiovascular Health: Implications for Women

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of mortality in adult women in the USA, yet CVD is underrecognized in women. Disparities in care are further pronounced in women of racial/ethnic minority backgrounds. In this review, we discuss the role of social media (SoMe) as a tool to (i) promote women's cardiovascular (CV) health and (ii) address and potentially reduce gaps in care, particularly in general cardiology (targeting atherosclerotic cardiovascular disease), cardio-oncology, and cardio-obstetrics. We also briefly discuss women's CV health as a common, although not unique, focus of women in cardiology on SoMe.

RECENT FINDINGS

Studies have suggested the utility of social media to help advance subspecialties of cardiology. Leaders within general cardiology, cardio-oncology, and cardio-obstetrics have curated social media strategies to advance their respective fields and call attention to cardiovascular health disparities in female populations and racial/ethnic minorities. In addition to these types of uses, women in cardiology also frequently use SoMe to encourage a career in cardiology and to share experiences, challenges, and resources for support and career advancement as healthcare professionals; men in cardiology and especially those who are allies for sex and racial/ethnic minorities also use SoMe for these means. Herein, we highlight the role and myriad applications of social media in the promotion of women's cardiovascular health. We discuss five primary roles of social media: increasing public awareness, disseminating medical literature in a rapid and accessible fashion, facilitating professional networking, serving as a platform for medical conferences, and empowering patients. These core strategies are discussed through the lens of general cardiology, cardio-oncology, and cardio-obstetrics. We also demonstrate how these applications can be leveraged to increase representation of women in cardiology, also supporting an increased focus on women's cardiovascular health.

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.

Younger Age Impacts Perceptions of Care Received in the Emergency Department Among Women with Spontaneous Coronary Artery Dissection

Background: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic etiology of acute coronary syndrome (ACS) that primarily affects younger women with few traditional cardiovascular disease risk factors. The primary objective of this study was to evaluate how younger age impacts the perception of care women receive in the emergency department (ED) at the time of their first or only SCAD. Methods: SCAD survivors were recruited using SCAD Alliance social media platforms to complete a one-time online survey regarding their experiences of seeking treatment for SCAD in the ED and their post-SCAD recovery. A total of 409 participants consented to participate in the parent study and data collected from the 367 participants who reported female gender were further analyzed. Results: Fewer participants <50 years old than would be expected under the null hypothesis (i.e., 65.5% observed vs. 71.2% expected, p = 0.009) reported perceived serious treatment by ED staff, more participants <50 years than would be expected under the null hypothesis (i.e., 12.0% observed vs. 9.3% expected, p = 0.049) reported perceived dismissive treatment by ED staff, and more participants <50 years than would be expected under the null hypothesis (i.e., 13.3% observed vs. 10.8% expected, p = 0.02) reported discharge from the ED without a diagnosis. Conclusions: Results of this study highlight the different experiences of younger SCAD survivors' engaging with providers in the ED. Further research regarding strategies for increasing ED providers' clinical interrogation of SCAD when treating and evaluating younger female patients presenting with ACS symptoms is indicated.

Cardiac rehabilitation in women, challenges and opportunities

Cardiac rehabilitation(CR) has known proven benefits in reducing mortality related to cardiovascular disease (CVD), improving quality of life (QoL), and preventing CVD-related readmissions. Despite these known benefits, CR remains underutilized among women relative to men. Disparities exist at the level of referral, enrollment, and program completion. Much is left to be understood regarding the utility of CR in female-predominant CVD such as postpartum cardiomyopathy and Spontaneous Coronary Artery Dissection. This review identifies the benefits of CR for specific populations of women and elucidates on the barriers to CR. We also describe current recommendations to overcome barriers to CR in women.

Physical Activity and Exercise Patterns After Spontaneous Coronary Artery Dissection: Insights From a Large Multinational Registry

Objective: The objective of the study was to assess the physical activity (PA) and exercise patterns among participants in a large multinational spontaneous coronary artery dissection (SCAD) registry. Patients and Methods: Participants with SCAD enrolled from March 2011 to November 2019 completed surveys including details regarding PA and exercise habits prior to SCAD, and PA counseling received from their provider after SCAD. Demographics and clinical characteristics were collected by electronic record review. Exercise prescribed to patients after SCAD was categorized according to exercise components: type, intensity, frequency, time/session, and extreme environmental conditions.

Results: We included 950 participants; mean ± age was 46.8 ± 9.5 years old at the time of first SCAD; most (96.3%) were women and (77.0%) attended ≥1 cardiac rehabilitation session. Hyperlipidemia (34.3%), hypertension (32.8%), and elevated body weight (overweight = 27.0%; obesity = 20.0%) were the most common comorbidities. Prior to SCAD, 48.5% performed aerobic exercise ≥3 times/week, and only 32.0% performed strength-building exercise regularly. PA counseling details after SCAD in 299/950 participants showed that most (93.3%) patients received some form of counseling including exercise prescription (EXP), non-specific recommendations, and discouraged from any exercise. Limits regarding exercise type and intensity were the most common advice among participants who received EXP.

Conclusion: Insights from our study suggest that only 48% of the patients performed some aerobic exercise three or more times per week, and 32.0% performed strength-building exercises, which suggest that most of them may not be as active as assumed. Furthermore, 70% of the SCAD patients have ≥1 cardiovascular risk factors. We suggest guiding patients based on individual assessment, taking into consideration baseline PA habits, treatment, and risk factors. SCAD-tailored PA guidelines are needed for optimal EXP without compromising patient safety.

A review of diagnosis, etiology, assessment, and management of patients with myocardial infarction in the absence of obstructive coronary artery disease

Myocardial infarction (MI) in the absence of obstructive coronary artery disease (MINOCA) is prevalent in around 5% of acute myocardial infarction (AMI) presentations. MINOCA is a heterogeneous entity with many different etiologies. It is important for health care providers to familiarize themselves with the disease process, presentation, and possible underlying causes in order to guide appropriate management strategies. In this article, the authors review the contemporary definition, etiologies and assessment, and management for AMI patients with MINOCA.

Cardiovascular prevention in women: a narrative review from the Italian Society of Cardiology working groups on 'Cardiovascular Prevention, Hypertension and peripheral circulation' and on 'Women Disease'

: Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in women.Some authors highlighted that the female risk profile consists of traditional and emerging risk factors. Despite the lower prevalence of type 2 diabetes, years of life lost owing to the disease for women are substantially higher compared with men. In addition, pregnancy complicated by gestational diabetes represents a risk factor for CVD. Women with gestational diabetes have a higher prevalence of coronary artery disease that occur at a younger age and are independent of T2DM.Hypertension is an important cardiovascular risk factor in women. Estrogens and progesterone, known to have an impact on blood pressure levels, have also been proposed to be protective against sleep-disordered breathing. It is very difficult to understand whereas obstructive sleep apnea in women is independently associated with hypertension or if many confounders acting at different stages of the woman lifespan mediate this relation.The cardioprotective effect of physical activity in women of all ages is well known. Women are generally more physically inactive than men. During and after menopause, most women tend to reduce their physical activity levels and together with the reduction in basal metabolic rate, women experience loss of skeletal muscle mass with a negative change in the ratio of fat-to-lean mass.In conclusion, sex differences in the cardiovascular system are because of dissimilarities in gene expression and sex hormones; these result in variations in prevalence and presentation of CVD and associated conditions, such as diabetes, hypertension and vascular and cardiac remodeling.Changes in lifestyle and increase in physical activity could help in prevention of cardiovascular disease in women.

Spontaneous Coronary Artery Dissection (SCAD): FEMALE SURVIVORS' EXPERIENCES OF STRESS AND SUPPORT

PURPOSE

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic type of acute myocardial infarction that primarily affects young, healthy women without typical risk factors for heart disease. Few investigations have examined psychosocial variables in this population and none have looked at patient perceptions of the experience and stresses associated with having a SCAD event or the resources currently available to SCAD survivors. This investigation describes survivors' subjective experiences of SCAD. Participants also provided information about types and helpfulness of resources available to them post-SCAD, including cardiac rehabilitation.

METHODS

Participants were recruited online and completed a one-time questionnaire.

RESULTS

Participants (n = 409) completed a questionnaire concerning their experiences with their SCAD event in the 1 y and 2 wk prior to the SCAD event. Their responses reflected moderate to high perceptions of stress. Participants experienced the SCAD event as highly stressful and frightening and their heart health presents as a moderate-severe source of current, post-diagnosis stress. Spontaneous coronary artery dissection-based informational support was frequently rated as inadequate, whereas other supportive resources varied in their helpfulness and accessibility. Participants reported positive experiences in cardiac rehabilitation and strong interest in SCAD-specific, professionally led, online patient education and support groups.

CONCLUSIONS

This study is the largest to date investigation of SCAD survivors and their experiences in this understudied and perhaps underrecognized condition. Opportunities for researchers and providers to develop, tailor, and disseminate SCAD-specific interventions are discussed.

Current state-of-play in spontaneous coronary artery dissection

For over 80 years, spontaneous coronary artery dissection (SCAD) has been recognised as a cause of myocardial infarction. SCAD is described as a non-iatrogenic, non-atherosclerotic coronary artery dissection, resulting in formation of a false lumen or intramural haematoma in the coronary artery wall that compresses the true lumen, often compromising myocardial blood flow. In early literature, the incidence of SCAD in acute coronary syndrome (ACS) was underestimated. Recent advances in awareness and widespread early angiographic investigation in ACS has led to important shifts in our understanding of the prevalence, predisposing causes, natural history, aetiology, clinical and angiographic features, management, and prognosis of SCAD. It is now well understood that SCAD predominantly affects women and is responsible for around 20% of ACS presentations in females below the age of 60. Despite this, SCAD is still often overlooked and misdiagnosed as atherosclerotic disease. Misdiagnosis is multifactorial; with contributing factors including a low clinical index of suspicion, particularly in young females, a lack of clinician familiarity with angiographic variants, and limitations of angiography. Although increasing evidence suggests that optimal management is distinct from atherosclerotic coronary artery disease, many questions remain unanswered regarding the pathogenesis and optimal treatment of SCAD, heralding prospective research to answer these questions. This review aims to give a current clinical perspective on SCAD and highlight the importance of familiarity and vigilance with this condition when diagnosing and treating ACS.

Comparison of reflex, resistance training, and core activities using change in blood pressure over time after spontaneous coronary artery dissection

A 53-year-old female athlete with spontaneous coronary artery dissection, acute myocardial infarction, and infrarenal abdominal aortic dissection enrolled in a 6-week cardiovascular rehabilitation (CR) program. During CR sessions, the patient performed a combination of aerobic, resistance training, and core activities. In the final CR session, the patient performed reflex activities and the forced Valsalva maneuver. The patient's electrocardiogram, blood pressure, heart rate, and transient change in blood pressure over time were continuously monitored and recorded. The patient completed CR without negative symptoms or adverse events.

Emerging misunderstood presentations of cardiovascular disease in young women

Background

Cardiovascular disease (CVD) remains the leading cause of death for females in the United States accounting for over 412 000 female deaths in 2016. CVD mortality in young women <55 years old remains significantly high and greater than that in men.

Hypothesis

There is a void with regards to awareness of CVD in women. Many traditional CVD risk estimate tools fail to identify the “at risk” female and is true for the young female patient. There needs to be a shift in focus from looking for the vulnerable plaque to looking for the “at risk” patient.

Methods

This review outlines the emerging misunderstood presentations of CVD in young women which include certain categories of myocardial infarction (MI) with non‐obstructive coronary arteries (MINOCA), such as spontaneous coronary artery dissection (SCAD), as well as the more stable myocardial ischemia with non‐obstructive coronary arteries (INOCA) category focusing on mental stress‐induced myocardial ischemia (MSIMI).

Results

The prevalence of MINOCA in patients presenting with MI is greater in women. In younger women with CVD, SCAD is an emerging misunderstood presentation in this group of patients with type 2 SCAD being the most common form. MSIMI, a form of INOCA, is more common in women with CVD.

Conclusions

There are emerging misunderstood factors that are prevalent in young women, such as SCAD and MSIMI. It is important to recognize their presentations in young women to prevent misdiagnosis, missed diagnosis as well as mismanagement of these patients to improve their clinical outcomes.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

High-intensity, sport-specific cardiac rehabilitation training of a 22-year-old competitive cyclist after spontaneous coronary artery dissection

A 22-year-old man with spontaneous coronary artery dissection wanted to assess the feasibility of returning to competitive cycling. He was referred to the cardiac rehabilitation (CR) program at Baylor Hamilton Heart and Vascular Hospital where staff designed a high-intensity, sport-specific training program that simulated the movements and forces associated with his goal activity. The program was symptom limited and enabled the patient to train earlier and at a higher intensity than is typically allowed in conventional CR programs. Daily exercise training was customized to match the physical demands of competitive cycling by using a road bike, an indoor bike power trainer, and an interactive indoor-cycling software program. This case illustrates how specialized CR training, tailored to a patient's specific goals, can aid in the return to vigorous physical activity. He completed the high-intensity exercise training program without adverse signs or symptoms.

Spontaneous Left Anterior Descending Coronary Artery Dissection Requiring Coronary Artery Bypass Surgery

Introduction

Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall, non-iatrogenic or trauma related, that has been recognized as an important cause of myocardial infarction.

Objective

To report an emblematic case, in terms of angiographic images, clinical presentation and predisposing factors, whose clinical management failure led to surgical intervention.

Methods

A previously healthy 48-year-old male farmer was admitted to the emergency room complaining of anterior chest pain described as "tearing", which started after physical exertion. Anterior wall ST-segment depression was observed in the electrocardiogram and troponin levels were increased. The patient then underwent coronary catheterization. Angiography showed a tortuous left anterior descending coronary artery with a dissection line involving proximal and middle segments, resulting in mild to moderate luminal stenosis. At first, a conservative approach was chosen. Control cardiac catheterization, 3 months later, showed dissection progression to the distal segment.

Results

The patient was referred to surgical treatment. Internal thoracic artery and a great saphenous vein graft were used to revascularize the target vessels. He had an uneventful postoperative course.

Conclusion

In this report, we describe a typical clinical manifestation of an uncommon cause of acute myocardial infarction. The dissection was started by an extreme physical effort, which is a known triggering factor. Management of these cases is always challenging because there are no evidence-based therapies or guideline-based recomendations.

Sudden Death from Spontaneous Coronary Artery Dissection due to Polyarteritis Nodosa

Spontaneous coronary artery dissection (SCAD) is an emerging and rare cause of acute coronary syndrome and sudden cardiac death. While it was previously reported among young females with fibromuscular dysplasia, new literature indicates that this condition could occur in older populations. Polyarteritis nodosa (PAN) causes systemic necrotizing vasculitis which typically affects small to medium-sized muscular arteries and could affect the coronary arteries. A few case reports of PAN causing acute coronary artery disease have been reported in the literature. We report a case of a 62-year-old lady who presented with abdominal pain and died abruptly during her stay; she was found to have PAN-associated SCAD on autopsy.

Spontaneous Coronary Artery Dissection in Pregnancy: What Every Obstetrician Should Know

Spontaneous coronary artery dissection is a major cause of myocardial infarction in pregnancy and the postpartum period. It occurs predominantly in young women with few or no conventional risk factors for atherosclerosis and has been clinically underrecognized. Treatment differs from that of myocardial infarction as a result of atherosclerosis and the diagnosis should be considered in all parturient and postpartum patients with acute coronary syndrome. Complications of spontaneous coronary artery dissection include recurrence, congestive heart failure, and death. Thus, specialist obstetrician-gynecologists and maternal-fetal medicine specialists need to gain knowledge of spontaneous coronary artery dissection to improve outcomes.

Clomiphene Associated Inferior STEMI in a Young Female due to Right Coronary Artery Dissection

Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is an uncommon cause of myocardial infarction. It most commonly affects females in the perimenopausal age. NA-SCAD has been associated with many predisposing factors including pregnancy and hormonal therapy for both contraception and ovulation induction. The presented case is a previously healthy 41-year-old woman diagnosed with inferior ST-elevation myocardial infarction due to right descending coronary artery dissection associated with recent use of clomiphene monotherapy for ovulation induction (a previously fertile woman), which was not previously reported. Learning Objectives. Emergency physicians (EPs) should be aware about NA-SCAD as a cause of acute coronary syndrome (ACS) especially in perimenopausal women even with no risk factors. NA-SCAD occurs more commonly in the postpartum period and in females following hormonal therapy. Here, clomiphene monotherapy was reported as a possible contributing factor to NA-SCAD. Guidelines for NA-SCAD management are not up to date, and EPs should avoid some interference before the final diagnosis of the cause of myocardial infarction.

Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non-atherosclerotic spontaneous coronary artery dissection (NA-SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA-SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow-up) to invasive angiographic procedures. Rarely, NA-SCAD has recurred in another coronary artery, ranging hours to years later. We report NA-SCAD of the right coronary artery (RCA) in a 30-year old, 3-month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA-SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA-SCAD recurrence in a subsequent pregnancy.

Cardiac rehabilitation after spontaneous coronary artery dissection

PURPOSE

Although cardiac rehabilitation (CR) improves outcomes in patients after atherosclerotic myocardial infarctions, little is known of the CR benefit among patients with spontaneous coronary artery dissection (SCAD), who are primarily young, otherwise healthy women. The purpose of this study was to describe SCAD patient outcomes in phase 2 outpatient CR.

METHODS

Patients with SCAD who enrolled in CR were retrospectively identified. Patients participated in standard CR, which included supervised and independent flexibility, stretching, aerobic, and strength training exercises. Patients received counseling regarding nutrition, weight and stress management. Assessments at baseline and program completion included cardiopulmonary exercise testing or 6-Minute Walk Test, body composition using plethysmography, depression (Patient Health Questionnaire-9), and stress (a scale of 1-10) scores.

RESULTS

Nine patients, all women, enrolled in CR an average of 12.3 days (range, 7-21 days) after their SCAD event, with one enrolling again after a recurrence. Cardiac rehabilitation was well received, with participants completing an average of 28 CR sessions (range, 5-39 sessions). Patients did not report cardiac symptoms and there were no adverse events during exercise testing or training. Peak oxygen uptake increased by an average of 18% (n = 4) and 6-minute walk distance increased 22% (n = 4). Average body mass decreased 1.1 kg, fat mass decreased 1.6 kg, and lean mass increased 0.4 kg. Depression and stress scores improved by an average of 2.3 and 1.3 points, respectively.

CONCLUSIONS

Standard CR beginning 1 to 2 weeks after SCAD seems to be feasible and safe and results in improved aerobic capacity, body composition, and measures of depression and stress. Because of these benefits, we recommend that patients with SCAD participate in CR.

Cardiovascular Disease in Women: Clinical Perspectives

Cardiovascular disease continues to be the leading cause of death among women in the United States, accounting for ≈1 of every 3 female deaths. Sex-specific data focused on cardiovascular disease have been increasing steadily, yet is not routinely collected nor translated into practice. This comprehensive review focuses on novel and unique aspects of cardiovascular health in women and sex differences as they relate to clinical practice in the prevention, diagnosis, and treatment of cardiovascular disease. This review also provides current approaches to the evaluation and treatment of acute coronary syndromes that are more prevalent in women, including myocardial infarction associated with nonobstructive coronary arteries, spontaneous coronary artery dissection, and stress-induced cardiomyopathy (Takotsubo Syndrome). Other cardiovascular disease entities with higher prevalence or unique considerations in women, such as heart failure with preserved ejection fraction, peripheral arterial disease, and abdominal aortic aneurysms, are also briefly reviewed. Finally, recommendations for cardiac rehabilitation are addressed.

Incidental Spontaneous Coronary Dissection: An Interventionist's Dilemma

Spontaneous coronary artery dissection (SCAD) is an uncommon entity, frequently presenting as ST-elevation myocardial infarction (MI) or sudden cardiac death. It is usually reported in association with pregnancy and has a high mortality. We present here a case of asymptomatic dissection of the right coronary artery, incidentally detected, in a young normotensive male when coronary angiography was done following acute anterior wall MI. This patient had none of the risk factors to which SCAD is generally ascribed. While management of the infarct-related artery was clear-cut, whether or not to intervene for this nonocclusive dissection was a difficult decision. A conservative approach was finally adopted for the spontaneous dissection and the patient is faring well till date.

What Clinicians Should Know Αbout Spontaneous Coronary Artery Dissection

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.

Spontaneous coronary artery dissection: Case series from two institutions with literature review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Consequently, its presentation and optimal treatment are yet to be clearly defined. In the current literature, all case series report less than 50 patients, most of whom are either young peripartum women or women who have used oral contraceptives over long periods. All information in this study was compiled by the database service from two hospitals, the first one between 2003 and 2012 and the second one between 2007 and 2012, to include the clinical characteristics, angiography. and treatment approaches in the study population. The study population consisted in four women (50%) and four men (50%) whose ages ranged between 28 and 57 years. Two women had a history of oral contraceptive use and three women presented during peripartum. None of the patients had traditional cardiovascular risk factors or previous heart disease. In 88% of the cases, the principal diagnoses were non-ST segment elevation myocardial infarction and unstable angina. All patients underwent emergency coronary angiography and percutaneous coronary intervention. Half of them were treated with drug-eluting stents and the other half with bare metal stents. The most frequent type of dissection was NIHBL Type E, and the right coronary artery was the most frequently compromised. SCAD is a rare cause of ACS; however, its identification has improved due to the availability of angiography and new complementary techniques. Regarding treatment, PCI seems effective with adequate long-term results.

[Pregnancy and coronary artery dissection]

Acute myocardial infarction during pregnancy is associated with high maternal and fetal mortality. Coronary atherosclerosis is the most common cause due to an increase in the age of the patients and the association with cardiovascular risk factors such as smoking, hypertension, diabetes mellitus, preeclampsia, and the existence of family history of coronary disease. However, thrombosis, coronary dissection or coronary vasospasms are other causes that may justify it. We report the case of a 33 weeks pregnant first-time mother, without cardiovascular risk factors, who presented an acute coronary event in the context of atherosclerotic disease and coronary dissection after percutaneous coronary intervention.

Sudden cardiac death due to coronary artery dissection as a complication of cardiac sarcoidosis

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS), cardiac tamponade and sudden cardiac death that typically affects young women in the postpartum period. Rarely, it can be caused by systemic inflammatory conditions such as sarcoidosis. Sarcoidosis is an inflammatory disease most often affecting the lung and lymph nodes that can sometimes affect the heart. The authors report a case of sudden cardiac death caused by SCAD in the context of undiagnosed and subclinical cardiac sarcoidosis. The decedent was a 47-year-old male with a relatively innocuous past medical history. He was found dead in bed. At autopsy, there was a lethal hemopericardium resulting in cardiac tamponade. Gross examination of the heart revealed dissection of the posterior descending coronary branch of the right coronary artery. Histologically, the coronary artery showed acute and organizing dissection with evidence of vasculitis. A chronic inflammatory infiltrate consisting of lymphocytes, histiocytes, eosinophils and giant cells was seen. Sections of the myocardium showed myocarditis with a nonnecrotizing granuloma. The death was attributed to cardiac tamponade secondary to SCAD in the context of systemic sarcoidosis. The presented case demonstrates two concurrent rare pathologies and highlights the importance of considering SCAD in cases of sudden cardiac death at autopsy.

Spontaneous coronary artery dissection: a case series and literature review

Spontaneous coronary artery dissection (SCAD) is a rare and often lethal cause of acute coronary syndrome, which typically affects young women and otherwise healthy individuals. SCAD can be diagnosed in patients undergoing coronary angiography and can be underestimated. Special techniques such as optical coherence tomography (OCT) and intravascular ultrasound should be used when there is suspicion of the condition. In the majority of cases, the left anterior descending (LAD) artery is involved; however, a few cases of the right coronary artery (RCA) involvement have been reported. This article describes three cases of SCAD in women of different ages, all presenting with chest pain. Coronary angiography in conjunction with OCT was used for diagnosis in two of the cases. One of the patients had involvement of the proximal RCA and underwent percutaneous coronary intervention, whereas the other two patients had mid-LAD disease and were treated conservatively with medical therapy. Presently, there are no specific guidelines for the treatment of SCAD, and therapy is individualized according to extent and severity of the condition.