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Morena A, Giacobbe F, De Filippo O, Angelini F, Bruno F, Siliano S, Giannino G, Dusi V, Bianco M, Biolé C, Varbella F, Cerrato E, D’Ascenzo F, De Ferrari GM. Advances in the Management of Spontaneous Coronary Artery Dissection (SCAD): A Comprehensive Review. Rev Cardiovasc Med 2024; 25:345. [PMID: 39355597 PMCID: PMC11440404 DOI: 10.31083/j.rcm2509345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/17/2024] [Accepted: 06/27/2024] [Indexed: 10/03/2024] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is a rare but significant cause of acute coronary syndrome (ACS), primarily affecting young women, often during pregnancy. Despite its rarity, SCAD poses challenges due to limited evidence on management strategies. This review examines the current state of art of SCAD management, integrating interventional and clinical insights from recent studies. The epidemiology of SCAD is related to its elusive nature, representing only a small fraction of ACS cases, while certainly underestimated. Proposed risk factors include genetic, hormonal, and environmental influences. Angiographic classification may help in SCAD diagnosis, but confirmation often relies on intracoronary imaging. Conservative management constitutes the primary approach, showing efficacy in most cases, although optimal antiplatelet therapy (APT) remains debated due to bleeding risks associated with intramural hematoma. Revascularization is reserved for high-risk cases, guided by angiographic and clinical criteria, with a focus on restoring flow rather than resolving dissection. Interventional strategies emphasize a minimalist approach to reduce complications, utilizing techniques such as balloon dilation and stent placement tailored to individual cases. Long-term outcomes highlight the risk of recurrence, necessitating vigilant follow-up and arrhythmic risk assessment, particularly in patients presenting with ventricular arrhythmias. In conclusion, SCAD management always represents a challenge for the physician, both from a clinical and interventional point of view. Recent clinical evidence and a multidisciplinary approach are vital for optimizing patient outcomes and preventing recurrence. This review offers a concise framework for navigating the complexities of SCAD management in clinical practice and proposes an algorithm for its management.
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Affiliation(s)
- Arianna Morena
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
| | - Federico Giacobbe
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
| | - Stefano Siliano
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
| | - Giuseppe Giannino
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
| | - Veronica Dusi
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
| | - Matteo Bianco
- Division of Cardiology, A.O.U San Luigi Gonzaga, 10043 Orbassano, Italy
| | | | - Ferdinando Varbella
- Interventional Cardiology Unit, Rivoli Infermi Hospital, 10098 Torino, Italy
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, 10043 Orbassano, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Torino, Italy
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
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Hosseini K, Fallahtafti P, Roudbari P, Soleimani H, Jahromi NA, Jameie M, Jenab Y, Moradi A, Ajam A, Heydari N, Kuno T, Narula N, Kampaktsis PN. Spontaneous coronary artery dissection in patients with prior psychophysical stress: a systematic review of case reports and case series. BMC Cardiovasc Disord 2024; 24:235. [PMID: 38702627 PMCID: PMC11067298 DOI: 10.1186/s12872-024-03902-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 04/24/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome, particularly in younger women. Due to limited information about SCAD, case reports and case series can provide valuable insights into its features and management. This study aimed to comprehensively evaluate the features of SCAD patients who experienced psychophysical stress before the SCAD event. METHODS We conducted an electronic search of PubMed, Scopus, and Web of Science from inception until January 7, 2023. We included case reports or series that described patients with SCAD who had experienced psychophysical stress before SCAD. Patients with pregnancy-associated SCAD were excluded from our analysis. RESULTS In total, we included 93 case reports or series describing 105 patients with SCAD. The average patient age was 44.29 ± 13.05 years and a total of 44 (41.9%) of patients were male. Among the included SCAD patients the most prevalent comorbidities were fibromuscular dysplasia (FMD) and hypertension with the prevalence of 36.4 and 21.9%, respectively. Preceding physical stress was more frequently reported in men than in women; 38 out of 44 (86.4%) men reported physical stress, while 36 out of 61 (59.1%) females reported physical stress (p value = 0.009). On the other hand, the opposite was true for emotional stress (men: 6 (13.6%)), women: 29 (47.6%), p value < 0.001). Coronary angiography was the main diagnostic tool. The most frequently involved artery was the left anterior descending (LAD) (62.9%). In our study, recurrence of SCAD due to either the progression of a previous lesion or new SCAD in another coronary location occurred more frequently in those treated conservatively, however the observed difference was not statistically significant (p value = 0.138). CONCLUSION While physical stress seems to precede SCAD in most cases, emotional stress is implicated in females more than males.
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Affiliation(s)
- Kaveh Hosseini
- Cardiac Primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Parisa Fallahtafti
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Payam Roudbari
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Soleimani
- Cardiac Primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran.
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran.
- Non-Communicable Disease Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, 1411713139, Iran.
| | - Negin Abiri Jahromi
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Mana Jameie
- Cardiac Primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Yaser Jenab
- Cardiac Primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Ali Moradi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Ajam
- Department of Medicine and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, USA
| | - Narges Heydari
- Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Toshiki Kuno
- Department of Medicine, Montefiore Medical Center, New York, NY, 10461, USA
| | - Nupoor Narula
- Weill Cornell Medicine, New York Presbyterian, New York City, USA
| | - Polydoros N Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
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D’Amato A, Mariani MV, Prosperi S, Colombo L, De Prisco A, Lavalle C, Mancone M, Vizza CD, Severino P. Spontaneous Coronary Artery Dissection in Clinical Practice: Pathophysiology and Therapeutic Approaches. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:217. [PMID: 38399505 PMCID: PMC10889982 DOI: 10.3390/medicina60020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 00161 Rome, Italy; (A.D.); (S.P.); (L.C.); (A.D.P.); (C.L.); (M.M.); (C.D.V.); (P.S.)
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Kaddoura R, Cader FA, Ahmed A, Alasnag M. Spontaneous coronary artery dissection: an overview. Postgrad Med J 2023; 99:1226-1236. [PMID: 37773985 DOI: 10.1093/postmj/qgad086] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/26/2023] [Indexed: 10/01/2023]
Abstract
The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fathima Aaysha Cader
- Department of Cardiology, Department of Cardiology, Kettering General Hospital, Kettering, Northants, NN16 8UZ, England
| | - Ashraf Ahmed
- Department of Internal Medicine, Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut 06610, United States
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital , Jeddah 21159, Saudi Arabia
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Denegri A, Szarpak L, Pruc M, Jaguszewski MJ. Spontaneous coronary artery dissection and Takotsubo syndrome. Eur J Intern Med 2023; 117:137-139. [PMID: 37586984 DOI: 10.1016/j.ejim.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Andrea Denegri
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Lukasz Szarpak
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, One Baylor Plaza - BCM285, Houston, TX 77030, USA.
| | - Michal Pruc
- Department of Public Health, International Academy of Ecology and Medicine, Kyiv, Ukraine
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Patail H, Sharma T, Aronow W, Haidry SA. Current challenges in treatment and management of spontaneous coronary artery dissection. Hosp Pract (1995) 2023; 51:192-198. [PMID: 37803492 DOI: 10.1080/21548331.2023.2268012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/04/2023] [Indexed: 10/08/2023]
Abstract
Though an infrequent cause of acute coronary syndrome, spontaneous coronary artery dissection is an increasingly recognized cardiovascular condition predominantly seen in middle-aged females. Its pathophysiology is defined by separation of coronary arterial wall layers which cause acute coronary syndrome-like presentations with relatively high recurrence rates. Overall, there is a lack of reported literature and understanding of the short- and long-term management for spontaneous coronary artery dissection. Therapeutic approaches include, but are not limited to, percutaneous coronary intervention, surgical revascularization, antithrombotic therapy, and beta-blocker therapy. There is a significant absence of randomized control trials to help guide both interventional and medical management for spontaneous coronary artery dissection. This review is aimed to review the current literature regarding risk factors and considerations for the short- and long-term management of spontaneous coronary artery dissection.
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Affiliation(s)
- Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Wilbert Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Syed Abbas Haidry
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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