Spontaneous Coronary Artery Dissection

How and when to suspect spontaneous coronary artery dissection: novel insights from a single-centre series on prevalence and angiographic appearance

AIMS

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed entity of acute coronary syndrome (ACS). Its prevalence remains unclear due to a challenging diagnosis, particularly in instances of intramural haematoma without intimal rupture. In the present study, we aimed to: 1) estimate the prevalence of SCAD among acute coronary syndrome (ACS) patients managed in a French coronary care centre, 2) demonstrate the value of specific angiographic signs for diagnosing SCAD, and 3) confirm the incremental value of intracoronary imaging in ambiguous cases.

METHODS AND RESULTS

From 1999 to 2014, 55 cases of SCAD (all women, mean age 50.1 years) were diagnosed. Ignoring age, 51 (92.7%) had ≤2 cardiovascular risk factors. Thirty-six were diagnosed prospectively during the latter period (2012-2014). Among these, SCAD accounted for 35.7% of ACS (20/56) in women <60 years with ≤1 cardiovascular risk factor. Upon close investigation, five angiographic features commonly observed with SCAD were identified: 1) absence of atheroma on other coronary arteries, 2) radiolucent flap(s), 3) contrast dye staining of the arterial wall, 4) starting and/or ending of the angiographic ambiguity on a side branch, 5) long narrowing of lumen calibre: smooth and linear, or stenosis of varying severity mimicking a "stick insect" or "radish" aspect. Three of the above five signs were present in 51 (92.7%) cases. Optical computed tomography (OCT) was performed in 19 cases with no complication. All explored arteries had evidence of intramural haematoma and/or intimomedial membrane separation. An intimal rupture was observed in 10 (52.6%) patients. The diseased segment initiated or ended on a side branch in 14 (73.7%) patients.

CONCLUSIONS

SCAD accounts for approximately one third of ACS in young women with ≤1 CRF. The combination of specific angiographic signs and OCT imaging facilitates the diagnosis of ambiguous cases without intimal rupture.

Spontaneous coronary artery dissection: new insights into diagnosis and treatment

Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.

Safety and efficacy of drug eluting stents in patients with spontaneous coronary artery dissection

AIMS

Given the different pathogenesis, use of drug eluting stent (DES) in patients with Spontaneous Coronary Artery Dissection SCAD may delay the healing of the dissected vessel. Aim of our study was to compare the safety and the efficacy of DES vs. bare metal stent (BMS) in a cohort of patients who underwent stenting for SCAD.

METHODS AND RESULTS

Consecutive patients with SCAD between January 1995 and August 2014 were retrospectively identified in 12 centers and included. Major Adverse Cardiac Events (MACE) was the primary end point. A total of 238 SCAD patients were identified: of them 108 patients underwent PCI with DES or BMS. Overall 24 patients (22.2%) suffered an intra-procedural complication without any differences between the 2 groups. At median follow-up of 1201days (Inter Quartile Range 541-2760), incidence of the primary endpoint showed a trend towards less events in the DES-treated patients (38.7% vs. 25.9% p=0.14) mainly driven by the benefit of DES in terms of TVR (17.6% vs. 4%, p=0.08), mortality (16.8% vs. 9.3%, p=0.4), and MI rate (16% vs. 8.4%, p=0.33). STEMI at presentation (HR 6.4, CI 95% 1.29-31.9, p=0.02) but not kind of stent (HR 0.97, CI 95% 0.2-4.7, p=0.9) emerged as independently related to prognosis at multivariable analysis.

CONCLUSIONS

In SCAD patients use of DES seems to be as safe as BMS with trend of better efficacy in the long term.

Right Coronary Dissection and Left Anterior Descending Thrombus: Dual Dilemma in a Young Cardiac Arrest Survivor

BACKGROUND

ST-elevation myocardial infarction (STEMI) leading to cardiac arrest is an exceptionally rare occurrence in young adults. Those affected tend to abuse sympathomimetic drugs, have strong family histories, or have a significant burden of cardiac risk factors. Another uncommon cause of STEMI is coronary artery dissection, which overwhelmingly affects middle- and older-aged women with few cardiac risk factors.

CASE REPORT

A 22-year-old athlete with no medical history was admitted to our institution post-cardiac arrest with an anterior STEMI and concomitant right coronary dissection. To our knowledge, this represents the first documented case of these simultaneous pathologies in a young cardiac arrest survivor. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Myocardial infarction is rare in young adults, and a diverse range of etiologies must be considered promptly to prevent delays in time-sensitive therapies, such as antiplatelet agents and revascularization. The emergency physician is most often the first point of contact in patients with acute coronary syndromes, and the failure to recognize it in young adults threatens them with premature death and potentially life-long disability.

Clinical presentation of patients with spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) especially in younger women. However, the clinical presentation and the acuity of symptoms prompting invasive management in SCAD patients have not been described. Understanding these presenting features may improve SCAD diagnosis and management.

METHODS

We reviewed SCAD patients who were prospectively followed at the Vancouver General Hospital SCAD Clinic. Their presenting symptoms and unstable features were obtained from detailed clinical histories and hospital admission documentation. Baseline characteristics, predisposing and precipitating conditions, angiographic findings, management strategies, in-hospital, and long-term events were recorded prospectively.

RESULTS

We included 196 SCAD patients who had complete documentation of their presenting symptoms. The majority were women (178/196; 90.8%) and all presented with MI (24.0% STEMI). The most frequent presenting symptom was chest discomfort, reported by 96%. Other symptoms included arm pain (49.5%), neck pain (22.1%), nausea or vomiting (23.4%), diaphoresis (20.9%), dyspnea (19.3%), and back pain (12.2%). Ventricular tachycardia/fibrillation occurred in 8.1% (16/196), with 1.0% having cardiac arrest. The time from symptom onset to hospital presentation was 1.1 ± 3.0 days. NSTEMI patients had longer delay for coronary angiography compared with STEMI (2.0 ± 2.5 days vs. 0.8 ± 1.7 days, P = 0.002). Overall, 34.2% had unstable symptoms upon arrival for coronary angiography. Those with unstable symptoms were more likely to undergo repeat angiography (65.7% vs. 50.4%, P = 0.049), and repeat or unplanned revascularization (14.9% vs. 5.4%, P = 0.033) during acute hospitalization.

CONCLUSION

Chest discomfort was the most frequent presenting symptom with SCAD and one-third had unstable symptoms prompting urgent invasive angiography. © 2017 Wiley Periodicals, Inc.

Changes in left ventricular function after spontaneous coronary artery dissection

BACKGROUND

Spontaneous healing of spontaneous coronary artery dissection (SCAD) and left ventricular ejection fraction (LVEF) recovery is frequently observed clinically. However, LVEF on presentation and follow-up imaging has not been described.

HYPOTHESIS

We hypothesize that LV dysfunction improves at follow-up after initial SCAD presentation.

METHODS

We included patients with nonatherosclerotic SCAD prospectively followed at Vancouver General Hospital, who had baseline assessment of LVEF and wall-motion abnormality (WMA) during their index presentation. A subset of these patients had repeat assessment of their ventricular function at follow-up. We compared the baseline LVEF and WMA with follow-up assessments and correlated to long-term cardiovascular outcomes.

RESULTS

We included 277 SCAD patients who had baseline ventricular assessment performed. The average age was 52.4 ± 9.4 years, and 90.3% were female. All presented with myocardial infarction (24.2% STEMI, 75.8% NSTEMI). At baseline, the mean LVEF was 55.6% ± 9.1% and 72/277 (26.0%) had LVEF <50%. The presence of WMA was observed in 237/277 (85.6%) cases. Of 164 patients with repeat assessments, the baseline LVEF was 54.6% ± 9.2%, with improvement to 60.7% ± 7.2% at follow-up (P < 0.001). Baseline LVEF of <50% was observed in 29.9%, but only 6.7% had LVEF <50% at follow-up (P < 0.001). Baseline WMA was observed in 87.2% but decreased to 44.5% at follow-up (P < 0.001). Multivariable analysis showed that presentation with STEMI (odds ratio [OR]: 2.71, P = 0.001), troponin I >50 µg/L (OR: 1.02, P = 0.005), and SCAD involvement of the LAD (OR: 2.5, P = 0.002) were independent predictors of baseline LVEF <50%.

CONCLUSIONS

In our large, prospectively followed SCAD cohort, the majority of patients presented with WMA and had relatively normal LVEF. Over half had subsequent normalization of WMA and LVEF on follow-up assessment.

Multimodality Imaging for Spontaneous Coronary Artery Dissection in Women

Spontaneous coronary artery dissection (SCAD) has gained attention as a key cause of acute coronary syndrome and sudden cardiac death among women. Recent advancements in cardiac imaging have improved identification and accelerated awareness of SCAD. Accurate diagnosis of SCAD through use of imaging is critical, as emerging evidence suggests that the optimal short- and long-term management strategies for women with SCAD differs substantially from that of women with atherosclerotic coronary disease. This review summarizes the application of both invasive and noninvasive imaging for the diagnosis, assessment, surveillance, and treatment of women affected by SCAD.

Simultaneous Idiopathic Dissections of the Coronary and Superior Mesenteric Arteries

A 49-year-old man complained of sudden upper abdominal pain but was not given a definitive diagnosis. The day after he was discharged, he noticed left chest pain. An in-depth electrocardiogram indicated acute myocardial infarction, and emergent coronary angiography revealed 99% stenosis of his left coronary artery. An intravascular ultrasound revealed spontaneous coronary artery dissection (SCAD), and the lesion was successfully stented. In an atherosclerosis screening, superior mesenteric artery dissection (SMAD) was confirmed, after which the lesion was successfully stented. This case suggests that SCAD and SMAD might have similar pathological backgrounds.

[Recent insights on spontaneous coronary artery dissection (SCAD): From diagnosis suspicion to long-term outcomes]

Spontaneous coronary artery dissection (SCAD) is a poorly understood and under-diagnosed entity of acute coronary syndrome, affecting predominantly young women. Relatively large series have been published in the past five years highlighting this condition, once believed to be rare. Indeed, the pathophysiology, natural history, clinical presentation, patient profile, diagnostic modalities, management and outcomes of SCAD are becoming better understood. The aim of our review is to provide a brief "state of the art" of SCAD in 2016 to help the clinician in the management of this challenging condition.

Multimodality imaging of fibromuscular dysplasia

OBJECTIVE

Fibromuscular dysplasia (FMD) is an uncommon non-inflammatory and non-atherosclerotic cause of arterial disease that may result in stenosis, tortuosity, aneurysm, or dissection. The clinical presentation depends on the vascular bed involved and ranges from asymptomatic to multisystem disease and end organ ischemia. The purpose of this article is to review the role of imaging in patients with FMD with an emphasis on renal FMD. The relevant epidemiology, histopathology, imaging techniques, and interpretation of images will be discussed.

CONCLUSION

Renal artery FMD requires a high index of suspicion for accurate and prompt diagnosis and implementation of appropriate therapy. The treatment will vary based on clinical presentation and distribution of involvement. Noninvasive imaging with duplex ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are reasonable alternatives for the depiction of FMD in comparison to catheter-directed angiography (CA). Patients with FMD are often treated by multispecialty practice including the interventional radiologist.

Outcomes of patients with spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an uncommon but serious condition presenting as an acute coronary syndrome (ACS) or cardiac arrest. The pathophysiology and outcomes are poorly understood. We investigated the characteristics and outcomes of patients presenting with SCAD.

METHODS

In a retrospective study of a large cohort of patients with SCAD, data were collected regarding clinical presentation, patient characteristics, vascular screening, coronary artery involvement and clinical outcomes.

RESULTS

40 patients with SCAD (95% women, mean age 45±10 years) were included. At least 1 traditional cardiovascular risk factor was present in 40% of patients. Migraine was reported in 43% of patients. Events preceding SCAD included parturition (8%), physical stress (13%), emotional stress (10%) and vasoconstrictor substance-use (8%). 65% of patients had a non-ST elevation ACS (NSTEACS) at presentation, 30% had an ST elevation myocardial infarction (STEMI) and 13% had a cardiac arrest. The left anterior descending artery was most frequently involved (68% of patients), and 13% had involvement of multiple coronary territories. Fibromuscular dysplasia (FMD) was identified in 7 (37%) of 19 patients screened. 68% of patients were managed medically, 30% had percutaneous coronary intervention and 5% had coronary artery bypass grafting. Over a median 16-month follow-up period, 8% of patients had at least 1 recurrent SCAD event. There were no deaths.

CONCLUSIONS

Patients with SCAD in this study often had multiple coronary territories involved (13%) and extracardiac vascular abnormalities, suggesting a systemic vascular process, which may explain the high incidence of migraine. All patients with SCAD should be screened for FMD and followed closely due to the possibility of recurrence.

Vascular Tortuosity May Be Associated With Cervical Artery Dissection

BACKGROUND AND PURPOSE

Dissection is an increasingly recognized cause of ischemic stroke, which occurs spontaneously or after trauma, in relatively young patients. We hypothesized that there might be a predisposing factor weakening the vascular wall and that arterial tortuosity might be higher in patients with dissection.

METHODS

We consecutively enrolled cervical artery dissection (CerAD) patients who had undergone magnetic resonance angiography. Age- and sex-matched healthy subjects who underwent magnetic resonance angiography in a routine health examination were used as controls. The tortuosity was measured semiautomatically from the carotid artery and vertebral artery (VA) arteries. Tortuosity index was defined as: [(arc/chord)-1×100] in each arteries. Independent risk factors associated with CerAD were investigated using multivariable analysis. Subgroup analysis according to the dissected artery was performed.

RESULTS

There were no differences in vascular risk factors between the 75 CerAD patients and the 75 controls. The tortuosity indexes of the contralesional VA (16.3±6.8 versus 12.1±4.5, respectively; P<0.001) and carotid artery (8.8±4.0 versus 7.3±2.9, respectively; P=0.01) were higher in patients with CerAD compared with those of control subjects. VA tortuosity (odds ratio, 1.175; P=0.001) was independently associated with the presence of CerAD. In subgroup analysis, VA tortuosity was significantly higher in 57 patients with VA dissection than in controls (P<0.001), and carotid artery tortuosity was marginally higher in 18 patients with carotid artery dissection (P=0.05).

CONCLUSIONS

CerAD is associated with tortuous cervical arteries, which may implicate weakened cervical vascular structure in these patients.

Postpartum spontaneous coronary, vertebral, and mesenteric artery dissections: a case report

BACKGROUND

Spontaneous coronary artery dissection is a rare cause of myocardial infarction that must always be considered on a clinician's differential diagnosis, particularly in patients <50-years old with a paucity of typical vascular risk factors.

CASE PRESENTATION

We describe a case of a 33-year-old white woman, 3 weeks postpartum, presenting with retrosternal chest and back pain, neck pain and stiffness, and intermittent headaches. Subsequent workup revealed concurrent spontaneous dissections in three separate medium-sized arterial beds.

CONCLUSIONS

She was successfully managed in a conservative fashion, highlighting that percutaneous or surgical revascularization can often be foregone in favor of conservative medical therapy.

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.

Imaging of acquired coronary diseases: From children to adults

Acquired coronary diseases include aneurysms, fistulae, dissections, and stenosis. Aneurysms may occur secondarily to Kawasaki disease, a childhood vasculitis, the prognosis of which depends on the coronary involvement, or they may be degenerative, infectious, inflammatory, or traumatic in origin. Fistulae develop between the coronary arterial system and a pulmonary or bronchial artery, or cardiac cavity. Dissections may occur spontaneously or may be post-traumatic. These coronary abnormalities may be found incidentally or may present as complications, infarction or rupture. The goals of this article are to understand acquired childhood and adult coronary diseases and their usual means of presentation, the ways of investigating them, and the principles of their treatment.

Epidemiology of fibromuscular dysplasia: A review of the literature

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory disease of medium sized arteries that has been described in multiple anatomic territories with a wide variety of manifestations (e.g. beading, stenosis, occlusion, aneurysm, or dissection). While the first case of FMD is thought to have been described over 75 years ago, the causes, natural history, and epidemiology of FMD in the general population remain incompletely understood. This article reviews important historical and contemporary contributions to the FMD literature that inform our current understanding of the prevalence and epidemiology of this important disorder. A particular focus is given to studies which form the basis for FMD prevalence estimates. Prevalence estimates for renal FMD are derived from renal transplant donor studies and sub-studies of clinical trials of renal artery stenting; however, it is unclear how well these estimates generalize to the overall population as a whole. Newer data are emerging examining the genetic associations and environmental interactions with FMD. Significant contributions to the understanding of FMD have come from the United States Registry for Fibromuscular Dysplasia; however, many unanswered questions remain, and future studies are required to further characterize FMD epidemiology in general populations and advance our understanding of this important disorder.

Spontaneous coronary artery dissection treated with biovascular scaffolds guided by intravascular ultrasounds imaging

We reported a case of a fit and active 48 years' old woman presented with acute coronary syndrome due to a spontaneous coronary dissection (SCAD) treated with bioresorbable scaffolds (BVS) implantation guided by intravascular ultrasounds (IVUS) with immediate and long-term good results.

Women and heart disease, the underrecognized burden: sex differences, biases, and unmet clinical and research challenges

For many years the significance of heart disease in women was vastly underappreciated, and women were significantly underrepresented in cardiovascular clinical research. We now know that cardiovascular disease is the leading cause of death for women. Women and men share many similarities in the pathophysiology and manifestations of heart disease. However, as research advances with the continued inclusion of more women, knowledge about gender differences between the female and male heart, both on a physiological and pathophysiological basis, grows. These differences can be found in all domains of cardiovascular health and disease, including heart rhythm, heart failure, coronary disease and valvular disease. Further understanding of gender differences in the heart is crucial for advancing our ability to maintain a healthy population and identify and treat heart disease in both women and men. Specific examples within the spectrum of heart disease will be discussed in this review paper, and areas for further research will be proposed.

Angiographic and Intracoronary Manifestations of Coronary Fibromuscular Dysplasia

BACKGROUND

We previously described a strong association between fibromuscular dysplasia (FMD) and spontaneous coronary artery dissection. Angiographic manifestations of coronary FMD aside from dissection were considered rare. However, we observed several coronary FMD angiographic abnormalities with corresponding optical coherence tomography abnormalities.

METHODS AND RESULTS

Baseline demographics and imaging of patients with suspected coronary FMD at Vancouver General Hospital were reviewed. Presence of multifocal (string-of-beads) extracoronary FMD was confirmed by 2 specialists. In these patients, coronary angiographic findings (excluding dissected segments) were reviewed and classified by 2 experienced angiographers for irregular stenosis, that is, stenosis with irregular borders in a focal or diffuse pattern with/without systolic accentuation; smooth stenosis, diffuse or focal; segmental dilatation/ectasia; and tortuosity. Optical coherence tomography was performed in a subset of patients. Of 32 patients with extracoronary FMD and suspected coronary involvement, 28 were women (88%), and their mean age was 59.4±9.9 years. Nineteen presented with myocardial infarction (13 caused by spontaneous coronary artery dissection), and 13 had stable symptoms. The observed coronary angiographic abnormalities included tortuosity in all cases (91% were moderate to severe), irregular stenosis in 59%, smooth stenosis in 19%, and segmental dilatation/ectasia in 56%. Fifteen patients had optical coherence tomography of the abnormal segments showing abnormalities, including multiple areas of patchy or diffuse intimal, medial or adventitial abnormalities with thickening/accumulation of varied reflectivities, macrophage infiltration, loss/duplication of elastic membranes, and cavitation.

CONCLUSIONS

This is the first case series describing findings suggestive of angiographic and intracoronary manifestations of coronary FMD. Future studies should prospectively review these features in patients with extracoronary FMD.

Acute coronary syndromes without coronary plaque rupture

The latest advances in plaque imaging have provided clinicians with opportunities to treat acute coronary syndrome (ACS) and provide individualized treatment recommendations based not only on clinical manifestations, angiographic characteristics, and biomarker data, but also on the findings of plaque morphology. Although a substantial proportion of ACS events originate from plaques with an intact fibrous cap (IFC), clinicians predominantly equate ACS with plaque rupture arising from thin-cap fibroatheromas. In this Review, we discuss the recent advances in our understanding of plaque morphology in ACS with IFC, reviewing contemporary data from intravascular imaging. We also explore whether use of such imaging might provide a roadmap for more effective management of patients with ACS.

Spontaneous coronary artery dissection and its association with heritable connective tissue disorders

OBJECTIVE

Spontaneous coronary artery dissection (SCAD) is an under-recognised but important cause of myocardial infarction and sudden cardiac death. We sought to determine the role of medical and molecular genetic screening for connective tissue disorders in patients with SCAD.

METHODS

We performed a single-centre retrospective descriptive analysis of patients with spontaneous coronary artery disease who had undergone medical genetics evaluation 1984-2014 (n=116). The presence or absence of traits suggestive of heritable connective tissue disease was extracted. Genetic testing for connective tissue disorders and/or aortopathies, if performed, is also reported.

RESULTS

Of the 116 patients (mean age 44.2 years, 94.8% women and 41.4% with non-coronary fibromuscular dysplasia (FMD)), 59 patients underwent genetic testing, of whom 3 (5.1%) received a diagnosis of connective tissue disorder: a 50-year-old man with Marfan syndrome; a 43-year-old woman with vascular Ehlers-Danlos syndrome and FMD; and a 45-year-old woman with vascular Ehlers-Danlos syndrome. An additional 12 patients (20.3%) had variants of unknown significance, none of which was thought to be a definite disease-causing mutation based on in silico analyses.

CONCLUSIONS

Only a minority of patients with SCAD who undergo genetic evaluation have a likely pathogenic mutation identified on gene panel testing. Even fewer exhibit clinical features of connective tissue disorder. These findings underscore the need for further studies to elucidate the molecular mechanisms of SCAD.

Focused Cardiovascular Care for Women: The Need and Role in Clinical Practice

Over the past decade, an emerging clinical research focus on cardiovascular (CV) disease (CVD) risk in women has highlighted sex-specific factors that are uniquely important in the prevention and early detection of coronary atherosclerosis in women. Concurrently, a 30% decrease in the number of female deaths from CVD has been observed. Despite this, CVD continues to be the leading cause of death in women, outnumbering deaths from all other causes combined. Clinical practice approaches that focus on the unique aspects of CV care for women are needed to provide necessary resources for the prevention, diagnosis, and treatment of CVD in women. In addition to increasing opportunities for women to participate in CV research, Women's Heart Clinics offer unique settings in which to deliver comprehensive CV care and education, ensuring appropriate diagnostic testing, while monitoring effectiveness of treatment. This article reviews the emerging need and role of focused CV care to address sex-specific aspects of diagnosis and treatment of CVD in women.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

The First Dedicated Cardiac Rehabilitation Program for Patients With Spontaneous Coronary Artery Dissection: Description and Initial Results

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in women, but the role of rehabilitation after SCAD is unclear.

METHODS

We designed a dedicated SCAD cardiac rehabilitation (SCAD-CR) program for our SCAD survivors at Vancouver General Hospital. This program encompasses a multidisciplinary approach including exercise rehabilitation, psychosocial counselling, dietary and cardiovascular disease education, and peer group support. Exercise and educational classes were scheduled weekly with a targeted participation of 6 months. Psychosocial counselling, mindful living sessions, social worker and psychiatry evaluations, and peer-group support were offered.

RESULTS

We report our first consecutive cohort of 70 SCAD women who joined SCAD-CR from November 2011 to April 2015. The average age was 52.3 ± 8.4 years. Mean participation duration was 12.4 ± 10.5 weeks; 28 completed 6 months, 48 completed ≥ 1 month. At entry, 44 (62.9%) had recurrent chest pains and average metabolic equivalents on exercise treadmill test was 10.1 ± 3.3. At program exit, the proportion with recurrent chest pains was lower (37.1%) and average metabolic equivalents was higher 11.5 ± 3.5 (both P < 0.001). There was a significant improvement in the STOP-D depression questionnaire, with mean scores of 13.0 ± 1.4 before and 8.0 ± 1.7 after the SCAD-CR (P = 0.046). Twenty (28.6%) social worker referrals and 19 (27.1%) psychiatry referrals were made. Mean follow-up was 3.8 ± 2.9 years from the presenting SCAD event, and the major cardiac adverse event rate was 4.3%, lower than our non-SCAD-CR cohort (n = 145; 26.2%; P < 0.001).

CONCLUSIONS

This is the first dedicated SCAD-CR program to address the unique exercise and psychosocial needs of SCAD survivors. Our program appears safe and beneficial in improving chest pain, exercise capacity, psychosocial well-being and cardiovascular events.

Prognostic impact of spontaneous coronary artery dissection in young female patients with acute myocardial infarction: A report from the Angina Pectoris-Myocardial Infarction Multicenter Investigators in Japan

BACKGROUND

We sought to compare the prognosis of patients with spontaneous coronary artery dissection (SCAD) and atherosclerosis as the cause of acute myocardial infarction (AMI), especially in young females.

METHODS AND RESULTS

A total of 20,195 patients with AMI at 20 institutions between 2000 and 2013 were retrospectively studied. Major adverse cardiac event (MACE: cardiac death, AMI or urgent revascularization) was the endpoint. The overall prevalence of SCAD was 0.31% (n=63; female, 94%). SCAD developed following emotional stress in 29% of patients. Revascularization was performed in 56% (35 of 63 patients), and SCAD recurrence developed in the originally involved vessel in 6 of 35 patients with revascularization, compared to none among 28 patients after conservative therapy (p=0.002). We compared the clinical characteristics of young female AMI patients aged ≤50years in the SCAD (n=45) and no-SCAD groups (atherosclerotic AMI, n=55). During a median follow-up of 50months, SCAD recurred in 27% of patients, of which 42% was in the first 30days. Kaplan-Meier analysis showed a significantly higher incidence of MACE in the SCAD group compared to the no-SCAD group (hazard ratio, 6.91; 95% confidence interval, 2.5 to 24.3; p<0.001), although the rate of successful percutaneous coronary intervention for SCAD was as high as 92%.

CONCLUSIONS

Young female patients with SCAD represent a high-risk subgroup of patients with AMI and require close follow-up.

Spontaneous coronary artery dissection: Case series and review of literature

AIM

Spontaneous coronary artery dissection (SCAD) is a less recognized cause of ST elevation myocardial infarction (STEMI) in clinical practice. The aim of this communication is to describe a case series in South Asian population and highlight on the long-term clinical outcomes on conservative management.

METHODS

A retrospective analysis of data of five patients (6 instances) of SCAD managed in a tertiary care center during January 1994 to June 2015 was done. Clinical, angiographic, therapeutic, and follow-up data till end of June 2015 are analyzed.

RESULTS

All patients were young (mean - 33 years) and predominantly male. Etiology of SCAD was diverse and included peripartum state, vigorous activity and atherosclerosis. Left anterior descending (LAD) coronary artery was predominantly involved and the majority had angiographic type 1 SCAD. Medical treatment provides excellent long-term benefits. Coronary stenting provided symptomatic benefit in a patient with favorable anatomy.

CONCLUSIONS

Clinical recognition of SCAD is difficult. It should be suspected in peripartum state, young females and in presence of other precipitating factors. Coronary angiography is essential for establishing the diagnosis. Medical treatment provides favorable long-term survival.

IMPLICATIONS AND PRACTICE

The awareness of SCAD is important for all clinicians involved in STEMI care. A prompt suspicion can avoid administration of thrombolytic therapy. Early coronary angiography will provide an accurate diagnosis and help in deciding appropriate therapy. Percutaneous intervention can be challenging.

Coronary Intramural Hematoma Presenting as Acute Coronary Syndrome

We herein report a case of intramural hematoma without ongoing myocardial ischemia that healed spontaneously with conservative treatment. A 37-year-old woman was admitted due to chest pain. Acute coronary syndrome was diagnosed by electrocardiography and echocardiography. Coronary angiography showed 90% stenosis in the distal portion of the left anterior descending coronary artery, where intravascular ultrasound showed a hematoma, but optical coherence tomography could not detect the entry point. Therefore, we identified the intramural hematoma as the etiology. Because the coronary flow was maintained and chest pain disappeared, we chose conservative treatment. Fifteen days after admission, coronary computed tomography showed an improvement in the intramural hematoma.

[Spontaneous coronary artery dissection and ST-segment elevation myocardial infarction (STEMI)]

Spontaneous coronary artery dissection (SCAD) is a poorly understood and under-diagnosed entity of acute coronary syndrome, affecting predominantly young women. On coronary angiography, the diagnosis remains challenging, particularly in case of intramural hematoma without intimal rupture. Intracoronary imaging, especially by optical coherence tomography (OCT), provides an incremental value in terms of diagnosis and management. We report the case of a 49-year-old woman admitted for STEMI caused by an intramural hematoma. In the discussion part, we aim to review the epidemiology, physiopathology, diagnosis, management and long-term prognosis of SCAD.

Spontaneous Coronary Artery Dissection: Case Series from a Tertiary Centre

Spontaneous coronary artery dissection (SCAD) is a rare cause of non-atherosclerotic acute coronary syndrome (ACS). As it is more commonly seen in young women, the diagnosis can be missed. Current evidence is based on case reports and retrospective studies with no consensus recommendations on immediate management and long-term follow-up. We present a case series of four patients to outline clinical presentation, prognosis and long-term management of this rare clinical entity.

Spontaneous Coronary Artery Dissection/Intramural Haematoma in Young Women with ST-Elevation Myocardial Infarction: "It Is Not Always a Plaque Rupture Event"

Spontaneous coronary artery dissection (SCAD) is an unusual, but increasingly recognized, cause of ST-elevation myocardial infarction (STEMI), especially among younger patients without conventional risk factors for coronary artery disease (CAD). Although dissection of the coronary intima or media is a hallmark finding, hematoma formation within the vessel wall is often present. It remains unclear whether dissection or hematoma is the primary event, but both may cause luminal stenosis and occlusion. The diagnosis of SCAD is made principally with invasive coronary angiography, although adjunctive intracoronary imaging modalities may increase the diagnostic yield. In STEMI patients, the decision whether to pursue primary percutaneous coronary intervention (PCI) or appropriate conservative medical therapy is based on clinical presentation, the extent of the dissection, the critical anatomy involvement, and the amount of ischaemic myocardium at risk. In this case report, we present two cases of young women with SCAD and STEMI, successfully treated with primary PCI. We briefly illustrate the characteristic aspects of the angiographic presentation and intravascular ultrasound-guided treatment. SCAD should always be considered in young STEMI patients without conventional risk factors for CAD with primary angioplasty to be required in patients with ongoing myocardial ischemia.

Stent mal-apposition with resorption of intramural hematoma with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). Conservative management is typically recommended but revascularization may be necessary if ongoing ischemia or adverse anatomical characteristics are present. Percutaneous coronary intervention (PCI) of SCAD can be fraught with challenges, and intracoronary imaging with optical coherence tomography (OCT) may provide insights on optimizing the acute results and identify long-term stent-related adverse events. We report three cases of SCAD treated with drug-eluting stents (DES) with OCT follow-up showing stent mal-apposition at different stages of follow-up. The clinical significance of these OCT findings and management options are discussed.

Statin-induced coronary artery disease regression rates differ in men and women

PURPOSE OF REVIEW

Whether statins are equi-efficacious in women and men continues to be debated. The potential antiatherosclerotic effects of high-intensity statin therapy on coronary atheroma in women compared with men have only very recently been characterized. This review aims to summarize the evidence underlying these recent observations.

RECENT FINDINGS

Coronary intravascular ultrasound (IVUS) is a highly sensitive plaque imaging tool, and serial changes of plaque burden on IVUS are known to associate with incident cardiovascular events. Study of coronary atheroma by intravascular ultrasound: effect of rosuvastatin versus atorvastatin was a randomized controlled trial employing serial IVUS to evaluate the antiatherosclerotic efficacy of high-dose rosuvastatin and atorvastatin during a 24-month study period. Study of coronary atheroma by intravascular ultrasound: effect of rosuvastatin versus atorvastatin revealed significantly greater coronary atheroma regression in women compared with men, particularly in the setting of lower achieved LDL cholesterol. Results of this analysis also identified a significant interaction between sex and type of statin used.

SUMMARY

These findings support the broad use of statins, especially high-intensity statins, in women with coronary artery disease, who may in fact derive greater benefit than men. These findings also suggest the need for dedicated clinical trials involving women, supporting the notion of more personalized therapeutic strategies for tackling atherosclerotic disease.

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.

Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging

BACKGROUND

The pathognomonic appearance of multiple radiolucent lumen on angiography is used to diagnose spontaneous coronary artery dissection (SCAD). However, this finding is absent in >70% of SCAD, in which case optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is useful to assess arterial wall integrity.

METHODS

We report the angiographic appearance of SCAD that were proven on intracoronary imaging with OCT or IVUS. Our angiographic classification and algorithm for SCAD diagnosis was previously reported. Patients with type 1 SCAD (multiple radiolucent lumen) do not require OCT/IVUS, whereas, it was recommended for those with suspected type 2 (diffuse stenosis) or 3 (mimic atherosclerosis) SCAD.

RESULTS

Twenty-two consecutive patients with non-type 1 angiographic SCAD in 25 coronary arteries (22 OCT and 4 IVUS) were studied. Mean age was 52.9 ± 9.9 years, 89.5% were women, and 16/22 (72.7%) had underlying fibromuscular dysplasia. Sixteen SCAD arteries were type 2 SCAD, and nine were type 3. All 25 SCAD arteries had intramural hematoma and intimomedial membrane separation with double lumen on OCT or IVUS. The mean visual angiographic stenosis was 74.6 ± 17.5% (range 40-100%). Dissected segments were long with mean qualitative coronary analysis (QCA) length 45.2 ± 29.2 mm, especially in patients with type 2 SCAD (mean QCA length 58.3 ± 29.0 mm). The mean QCA length in type 3 SCAD lesions was 22.1 ± 5.7 mm.

CONCLUSIONS

Intracoronary imaging confirms that SCAD may appear angiographically without multiple radiolucent lumen. Angiographers should be familiar with angiographic SCAD variants to improve SCAD diagnosis, and utilize intracoronary imaging when the diagnosis is uncertain.

[Postpartum acute coronary syndrome secondary to spontaneous coronary dissection: report of a case]

L'IDM per gravidique est une complication grave qui entraine une morbidité et une mortalité maternelle élevée. Bien que l'athérosclérose soit la cause d'IDM la plus fréquente dans la population générale, elle n'est observée que chez un tiers des femmes enceintes. Chez ces dernières, la cause la plus fréquente d'IDM était la dissection coronaire. Nous rapportons l'observation clinique d'une jeune femme de 24 ans, sans facteur de risque cardiovasculaire, qui a présenté un IDM antérieur étendu 15 jours après un accouchement, en rapport avec une dissection de la partie proximale de l'artère inter ventriculaire antérieure. Le traitement de cette pathologie n'est pas consensuel, et peut faire appel, selon la présentation clinique et angiographique, au traitement médical, à une revascularisation par pontage aorto-coronaire avec une résection de l'hématome de la paroi artérielle, ou à l'angioplastie transluminale. Le pronostic semble assez favorable quoique controversé.