Scientific statement on spontaneous coronary artery dissection: care must be taken not to miss the association of spontaneous coronary artery dissection and takotsubo syndrome

Myocardial Infarction with Non-Obstructive Coronary Arteries: A Puzzle in Search of a Solution

Background

The term myocardial infarction with non-obstructive coronary arteries (MINOCA), defines a puzzling event occurring in the absence of obstructive coronary artery disease on coronary angiography and without an overt potential cause. However, a practical diagnostic work-up is often difficult, due to the heterogeneous etiologies and pathophysiology of MINOCA. This review aims to provide a comprehensive overview focusing on epidemiology, etiopathogenesis, diagnostic tools and therapeutic strategies for subjects with MINOCA, in order to provide a prompt and accurate diagnostic work-up and an adequate therapeutic approach in this subset population.

Methods

This educational review was carried out by following the standard methods of the Cochrane Collaboration and the PRISMA statement. The terms "MINOCA" OR ("myocardial infarction" AND ("non-obstructive" OR "non-obstructive")) were searched in PubMed and Embase databases (in Title and/or Abstract) from 1st January 2003 until 31st May 2022.

Results

Etiologic findings, clinical presentation and the degree of hemodynamic impairment play a pivotal role in defining the patient's natural history and prognostic outcome, and may significantly impact on the decision-making strategies and therapeutic approaches.

Conclusions

Despite further advances in diagnostic and therapeutic strategies, MINOCA remains a challenging conundrum in clinical practice. Clinicians should be aware of the different potential etiologies and pathogenic mechanisms of MINOCA, in order to carry out a comprehensive diagnostic work-up and implement a tailored therapeutic approach.

Recurrent Spontaneous Coronary Artery Dissection: Association with Takotsubo Syndrome and Fibromuscular Dysplasia; Comprehensive Review

Spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-iatrogenic, and non-atherosclerotic separation or dissection of the coronary arterial wall by the formation of an intramural hematoma causing a false lumen leading to compression of the true lumen with a varying degree of coronary blood flow obstruction. One of the important and frequent complications of the disease is the in-hospital and long-term SCAD recurrence. SCAD associated with takotsubo syndrome (TS) has been described in case reports, series of cases and in some studies. Some investigators believe that the association of SCAD and TS is a misdiagnosis. The association of SCAD and fibromuscular dysplasia (FMD) has received major attention during the last 10 years. In this report, the short and long-term SCAD recurrence, SCAD association with TS and FMD are reviewed and demonstrated with illustrative images.

Spontaneous Coronary Artery Dissection: A Comprehensive Overview

Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome that primarily impacts young women. Spontaneous coronary artery dissection as a cause of acute coronary syndrome is not rare and should not be overlooked. Spontaneous coronary artery dissection should be considered on the list of differential diagnosis of any chest pain occurring in young women with few typical risk factors. The purposes of this article are to broaden the understanding and increase awareness of spontaneous coronary artery dissection, specifically its diagnosis and clinical outcomes.

Autonomic neurocardiogenic syndrome is stonewalled by the universal definition of myocardial infarction

Myocardial infarction (MI) is defined as myocardial cell death due to prolonged myocardial ischemia. Clinically, troponin rise and/or fall have become the “defining feature of MI” according to the universal definition of MI (UD-MI). Takotsubo syndrome (TS) and TS-related disease conditions also cause troponin elevation with typical rise and/or fall pattern but through a mechanism other than coronary ischemia. By strict application of the clinical diagnostic criteria for type-1 MI, type-2 MI, type-3 MI, and MI with non-obstructive coronary arteries according to the UD-MI including the fourth one published recently, TS and most of the 26 other causes of troponin elevation mentioned in the fourth UD-MI may erroneously be classified as MI. The existing evidence argues for the case that TS by itself is not a MI. Hyper-activation of the autonomic-sympathetic nervous system including local cardiac sympathetic hyper-activation and disruption with nor-epinephrine churn and spillover is the most probable cause of TS. This autonomic neuro-cardiogenic (ANCA) mechanism results in myocardial “cramp” (stunning), the severity and duration of which depend on the degree of the sympathetic-hyperactivation and nor-epinephrine spillover. The myocardial cramp may squeeze the cytosolic free troponin pools causing mild to moderate troponin elevation in TS and TS-related disease conditions. This ANCA syndrome, which has hitherto been enveloped by the UD-MI over more than one decade, may occur in acute, recurrent, and chronic forms. In this critical review, the controversies of UD-MI, evidence for ANCA syndrome, and a hypothetical mechanism for the troponin elevation in ANCA syndrome are provided.