Usefulness of Cardiac Rehabilitation After Spontaneous Coronary Artery Dissection

The comprehensive care of the post-SCAD patient

Spontaneous coronary artery dissection (SCAD) is the nonatherosclerotic, nontraumatic dissection of an epicardial coronary artery which is predominantly caused by intramural hematoma formation or intimal disruption. SCAD is an increasingly recognized cause of acute coronary syndrome (ACS) in young women and its true prevalence may be underestimated due to its underdiagnosis. The pathogenesis of SCAD is multifaceted and influenced by gender-specific factors, hormonal fluctuations, genetics, arteriopathies, and physical and emotional stressors. Although the pathogenesis of SCAD is multifaceted, current guidance on the care of the post-SCAD patient is limited. Moreover, it is necessary to address each of the different components contributing to the pathogenesis of SCAD in order to improve outcomes and quality of life in this patient population. This literature review aims to consolidate the current knowledge on the medical management, rehabilitation, reproductive and mental health care, and comorbidities that affect SCAD survivors.

Patients' perspective of quality-of-care and its correlation to quality-of-life following spontaneous coronary artery dissection

AIMS

Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of myocardial infarction. We aimed to investigate SCAD survivors' perceptions of their quality-of-care and its relationship to quality-of-life.

METHODS AND RESULTS

An anonymous survey was distributed online to SCAD survivors involved in Australian SCAD support groups, with 172 (95.3% female, mean age 52.6 ± 9.2 years) participants in the study. The survey involved assessment of quality-of-life using a standardized questionnaire (EQ-5DTM-3L). Respondents rated the quality-of-care received during their hospital admission for SCAD with a median of 8/10 [interquartile range (IQR) 7-10]. Respondents ≤ 50 years vs. >50 years were more likely to perceive that their symptoms were not treated seriously as a myocardial infarction (χ2 = 4.127, df = 1, P < 0.05). Participants rated clinician's knowledge of SCAD with a median of 4/10 (IQR 2-8) and 7/10 (IQR 3-9) for Emergency and Cardiology clinicians, respectively (P < 0.05). The internet was the most selected source (45.4%) of useful SCAD information. The mean EQ-5DTM summary index was 0.79 (population norm 0.87). A total of 47.2% of respondents reported a mental health condition diagnosis, with 36% of these diagnosed after their admission with SCAD. Quality-of-life was significantly associated with perceived quality-of-care: EQ-5DTM index/(1-EQ-5DTM index) increased by 13% for each unit increase in quality-of-care after adjusting for age and comorbidities (P < 0.001).

CONCLUSION

While SCAD survivors rated their overall hospital care highly, healthcare providers' knowledge of SCAD was perceived to be poor, and the most common source of SCAD information was the internet. Mental health conditions were common, and a significant association was observed between perceived quality-of-care and SCAD survivors' quality-of-life.

Spontaneous coronary artery dissection: a focus on post-dissection care for the vascular medicine clinician

Spontaneous coronary artery dissection (SCAD) is an uncommon condition which is increasingly recognized as a cause of significant morbidity. SCAD can cause acute coronary syndrome and myocardial infarction (MI), as well as sudden cardiac death. It presents similarly to atherosclerotic MI although typically in patients with few or no atherosclerotic risk factors, and particularly in women. As more patients are recognized to have this condition, there is a great need for clinician familiarity with diagnostic criteria, as well as with contemporary treatment approaches, and with appropriate patient-centered counseling, including genetic testing, exercise recommendations, and psychological care. The standard of care for patients with SCAD is rapidly evolving. This review therefore summarizes the diagnosis of SCAD, epidemiology, modern treatment, cardiac rehabilitation and preconception counseling, and the current approach to genetic testing, exercise recommendations, and psychological care, all of which are crucial to the vascular medicine specialist.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient-Informed Investigation

BACKGROUND

Clinical practice guidelines for the management and convalescence of patients with spontaneous coronary artery dissection (SCAD) have yet to be developed. The targeted content, delivery, and outcomes of interventions that benefit this population remain unclear. Patient-informed data are required to substantiate observational research and provide evidence to inform and standardize clinical activities.

METHODS AND RESULTS

Patients diagnosed with SCAD (N=89; 86.5% women; mean age, 53.2 years) were purposively selected from 5 large tertiary care hospitals. Patients completed sociodemographic and medical questionnaires and participated in an interview using a patient-piloted semistructured interview guide. Interviews were transcribed and subjected to framework analysis using inductive and then deductive coding techniques. Approximately 1500 standard transcribed pages of interview data were collected. Emotional distress was the most commonly cited precipitating factor (56%), with an emphasis on anxiety symptoms. The awareness and detection of SCAD as a cardiac event was low among patients (35%) and perceived to be moderate among health care providers (55%). Health care providers' communication of the prognosis and self-management of SCAD were perceived to be poor (79%). Postevent psychological disorders among patients were evident (30%), and 73% feared recurrence. Short- and longer-term follow-up that was tailored to patients' needs was desired (72%). Secondary prevention programming was recommended, but there were low completion rates of conventional cardiac rehabilitation (48%), and current programming was deemed inadequate.

CONCLUSIONS

This early-stage, pretrial research has important implications for the acute and long-term management of patients with SCAD. Additional work is required to validate the hypotheses generated from this patient-oriented research.

What do spontaneous coronary artery dissection survivors want to support their recovery? a qualitative study

AIMS

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as an important cause of myocardial infarction predominantly affecting women aged younger than 50 years. There is limited research addressing female and male SCAD survivors' experience of, or requirements for, support post-SCAD. This study explored what SCAD survivors wanted to support recovery.

METHODS AND RESULTS

A qualitative study using semi-structured video and telephone interviews. Data were analysed through thematic analysis using the framework approach. We interviewed 20 participants (19 females) with a mean age of 54.6 (+/-SD 8.5 years). Three overarching themes encapsulated participants' views about support requirements. (i) Education and information. Participants thought healthcare professionals involved in diagnosis and supporting recovery required greater awareness of SCAD and the psychological effect of SCAD. They wanted accessible SCAD information immediately post-event and during the educational component of cardiac rehabilitation. (ii) Physical activity. Requirements were for advice tailored to individuals' specific needs, physical capabilities, and physical activity preferences. Participants suggested that utilizing wearable technology was helpful to encourage a safe return to activity. (iii) Psychosocial support. Participants wanted formal psychosocial support immediately post-event, during cardiac rehabilitation and in the longer term.

CONCLUSION

Better healthcare professional training may improve diagnosis, and increase support and awareness of SCAD. SCAD support programmes should provide early SCAD specific education utilizing online sources, individually tailor physical activity prescription, offer wearable technology to support a return to being active, and provide short- and long-term psychosocial support. As SCAD is predominately a female condition, programmes should consider female physical activity preferences.

Regional and temporal variations of spontaneous coronary artery dissection care according to consensus recommendations: a systematic review and meta-analysis

AIM

The first expert consensus documents on management of patients with spontaneous coronary artery dissection (SCAD) were published in 2018. Worldwide quality of care, as measured by adherence to these recommendations, has not been systematically reviewed. We aim to review the proportion of patients with SCAD receiving consensus recommendations globally, regionally and, determine differences in practice before and after 2018.

METHODS AND RESULTS

A systematic review was performed by searching four main databases (Medline, Embase, SCOPUS, CINAHL) from their inception to 16 June 2022. Studies were selected if they included patients with SCAD and reported at least one of the consensus document recommendations. 53 studies, n=8456 patients (mean 50.1 years, 90.6% female) were included. On random effects meta-analysis, 92.1% (95% CI 89.3 to 94.8) received at least one antiplatelet, 78.0% (CI 73.5 to 82.4) received beta-blockers, 58.7% (CI 52.3 to 65.1) received ACE inhibitors or aldosterone receptor blockers (ACEIs/ARBs), 54.4% (CI 45.4 to 63.5) were screened for fibromuscular dysplasia (FMD), and 70.2% (CI 60.8 to 79.5) were referred to cardiac rehabilitation. Except for cardiac rehabilitation referral and use of ACEIs/ARBs, there was significant heterogeneity in all other quality-of-care parameters, across geographical regions. No significant difference was observed in adherence to recommendations in studies published before and after 2018, except for lower cardiac rehabilitation referrals after 2018 (test of heterogeneity, p=0.012).

CONCLUSION

There are significant variations globally in the management of patients with SCAD, particularly in FMD screening. Raising awareness about consensus recommendations and further prospective evidence about their effect on outcomes may help improve the quality of care for these patients.

Secondary Prevention and Rehabilitation for Spontaneous Coronary Artery Dissection: A Systematic Review

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a serious, noniatrogenic and nontraumatic cardiac event that predominantly affects women, with a high risk of recurrence. Secondary prevention strategies are not well understood in this population. Therefore, the aim of this systematic review is to determine the current evidence on secondary prevention strategies and their effect on recurrent cardiac events and quality of life (QOL).

METHODS

A literature search was conducted on August 21, 2021, of Ovid MEDLINE, Ovid Embase, CINAHL, Cochrane Library (via Wiley), Google Scholar, and ProQuest Dissertations & Theses Global. Literature on adult SCAD survivors who underwent secondary prevention measures with reported outcomes on major adverse cardiovascular events or QOL were included. Articles solely on pregnancy-associated SCAD or fibromuscular dysplasia were excluded.

RESULTS

Thirty studies were included in this review. A variety of research methodologies were explored. There were no randomized controlled trials. Overall, the quality of the evidence was moderate. Although evidence on secondary prevention was limited, tailored medical management was shown to have the most effect on decreasing recurrent events. Cardiac rehabilitation (CR) was supported as a safe and effective program for SCAD patients, with no reported associations with recurrent SCAD events or major adverse cardiovascular events. CR along with psychosocial interventions showed promise in improving QOL in SCAD survivors.

CONCLUSIONS

Medical management has the most effect in reducing recurrent events. CR, as a secondary prevention program, can provide interventions that might improve QOL. Randomized trial evidence on therapies for patients with SCAD are needed.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Spontaneous Coronary Artery Dissection: A Review of Epidemiology, Pathophysiology and Principles of Management

Spontaneous coronary artery dissection (SCAD) is a sudden rupture of coronary artery wall leading to false lumen and intramural hematoma formation. It commonly occurs in young and middle-aged women lacking typical cardiovascular risk factors. Fibromuscular dysplasia and pregnancy are strongly associated with SCAD. To date, the "inside-out" and "outside-in" are the two proposed hypothesis for the pathogenesis of SCAD. Coronary angiography is the gold standard and first line diagnostic test. Three types of SCAD have been described according to coronary angiogram. Intracoronary imaging modalities are reserved for patients with ambiguous diagnosis or to guide percutaneous coronary intervention view the increased risk of secondary iatrogenic dissection. The management of SCAD includes conservative approach, coronary revascularization strategies accounting for percutaneous coronary intervention and coronary artery bypass graft, and long-term follow-up. The overall prognosis of patients with SCAD is favorable marked by a spontaneous healing in a large proportion of cases.

The Australian New Zealand Spontaneous Coronary Artery Dissection (ANZ-SCAD) Registry - A Multi-Centre Cohort Study: Protocol, Background and Significance

INTRODUCTION

Spontaneous coronary artery dissection (SCAD) is an under-recognised cause of acute coronary syndrome (ACS) with a strong female predominance. There are currently limited prospective studies and no randomised controlled trials that inform on SCAD's best clinical care. Little is also known about predictors of acute SCAD deterioration or recurrence. We describe the study design of a multi-centre prospective and historical cohort study recruiting patients with SCAD across 15-20 sites in Australia/New Zealand (NZ). The primary aim is to describe the clinical presentation, management and outcomes along with predictors of acute deterioration and recurrence in a large Australian/NZ SCAD cohort, with international data pooling.

METHODS AND ANALYSIS

Consented patients diagnosed with SCAD during a hospital admission for an ACS will be prospectively followed at 30 days then yearly, for up to 5 years. Each recruiting site will also retrospectively identify historical cases of SCAD from the proceeding 10 years, with a waiver of consent. For historical cases, data will be collected in a de-identified manner with date of last follow-up or death obtained from the medical records. All cases undergo core laboratory adjudication of coronary angiography and any accompanying imaging to confirm SCAD diagnosis. The primary endpoint will be occurrence of major adverse cardiovascular events; a composite of all-cause mortality, recurrent myocardial infarction (including SCAD recurrence), stroke/transient ischaemic attack, heart failure, cardiogenic shock, cardiac arrest/ventricular arrhythmia, heart transplantation and, repeat/unplanned revascularisation. Secondary endpoints will include each individual primary outcome as well as acute SCAD extension and quality of life/Seattle Angina Score in prospectively recruited participants. Endpoints will be assessed at the end of the hospital admission and at 30-days, 1 year, and median long-term follow-up.

ETHICS

Multicentre ethics approval has been granted from the Western Sydney Local Health District Human Research Ethics Committee (2021/ETH00040).

DISSEMINATION OF RESULTS

The analysed results will be published in peer-reviewed journals on completion of the historical data collection and then on completion of the prospective data collection.

REGISTRATION DETAILS

The ANZ-SCAD registry has been prospectively registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12621000824864).

Individualized exercise prescription and cardiac rehabilitation following a spontaneous coronary artery dissection or aortic dissection

Aims

Prescribed aerobic-based exercise training is a low-risk fundamental component of cardiac rehabilitation (CR). Secondary prevention therapeutic strategies following a spontaneous coronary artery dissection (SCAD) or aortic dissection (AD) should include CR. Current exercise guidance for post-dissection patients recommends fundamental training components including target heart rate zones are not warranted. Omitting fundamental elements from exercise prescriptions risks safety and makes it challenging for both clinicians and patients to understand and implement recommendations in real-world practice. We review the principles of exercise prescription for CR, focusing on translating guidelines and evidence from well-studied high-risk CR populations to support the recommendation that exercise testing and individualized exercise prescription are important for patients following a dissection.

Methods and results

When patients self-perceive exercise intensity there is a tendency to underestimate intensities within metabolic domains that should be strictly avoided during routine exercise training following a dissection. However, exercise testing associated with CR enrolment has gained support and has not been linked to adverse events in optimally medicated post-dissection patients. Graded heart rate and blood pressure responses recorded throughout exercise testing provide key information for developing an exercise prescription. An exercise prescription that is reflective of medical history, medications, and cardiorespiratory fitness optimizes patient safety and yields improvements in blood pressure control and cardiorespiratory fitness, among other benefits.

Conclusion

This clinical practice and education article demonstrates how to develop and manage a CR exercise prescription for post-acute dissection patients that can be safe and effective for maintaining blood pressure control and improving cardiorespiratory fitness pre-post CR.

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.

Health status outcomes after spontaneous coronary artery dissection and comparison with other acute myocardial infarction: The VIRGO experience

Background

Data on health status outcomes after spontaneous coronary artery dissection (SCAD) are limited.

Methods and findings

Using the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study we compared patients with SCAD and other acute myocardial infarction (AMI) at presentation (baseline), 1-month, and-12 months using standardized health status instruments. Among 3572 AMI patients ≤ 55 years, 67 had SCAD. SCAD patients were younger (median age (IQR) 45 (40.5–51) years vs. 48 (44–52) in other AMI, p = 0.003), more often female (92.5% vs. 66.6%), have college education (73.1% vs. 51.7%) and household income >$100,000 (43.3% vs. 17.7% (All p<0.001). SCAD patients at baseline had higher mean ± SD Short Form-12 [SF-12] physical component scores [PCS] (48.7±10.2 vs. 43.8±12.1, p<0.001) and mental component scores [MCS] (49.6±12.4 vs. 45.4±12.5, p = 0.008), and at 12-months [PCS (50.1±9.0 vs. 44.3±12.3, p<0.001) and MCS (53±10.1 vs 50.2±11.0, p = 0.045)]. The Euro-Quality of Life Scale [EQ-5D] VAS and EQ-5D index scores were similar at baseline, but higher at 12-months for SCAD (EQ-5D VAS: 82.2±10.2 vs. 72.3±21.0, p<0.001; EQ-5D index scores; 90.2±15.3 vs. 83.7±19.8, p = 0.012). SCAD patients had better baseline Seattle Angina Questionnaire [SAQ] physical limitation (88.8±20.1 vs. 81.2±25.4, p = 0.017). At 12-months SCAD patients had better physical limitation (98.0±8.5 vs. 91.4±18.8, p = 0.007), angina frequency (96.4±8.8 vs. 91.3±16.8, p = 0.018) and quality of life scores (80.7±14.7 vs 72.2±23.2, p = 0.005). Magnitude of change in health status from baseline to 12-months was not statistically different between the groups. After adjustment for time and comorbidities there remained no difference in most health status outcomes.

Conclusions

SCAD patients fare marginally better than other AMI patients on most health status instruments and have similar 12-month health status recovery. Better pre-event health status suggests a need to modify exercise prescriptions and cardiac rehabilitation protocols to better assist this physically active population to recover.

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.

Spontaneous Coronary Artery Dissection: New Insights into This Not-So-Rare Condition

Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute myocardial infarction (MI) among young and middle-aged women and is an important cause of pregnancy-associated MI. Over 90% of SCAD patients are women. Compared to patients with MI caused by atherosclerosis, SCAD patients have fewer cardiovascular risk factors but more often have systemic arteriopathy, most commonly fibromuscular dysplasia. Angiographically, SCAD is characterized by the presence of an intramural hematoma with or without an intimal tear. Accurate recognition of characteristic findings on coronary angiography is critical, as there are important differences in the acute and long-term management of MI caused by SCAD versus atherosclerosis. Acutely, most SCAD patients should be managed conservatively, since percutaneous revascularization is associated with more complications and SCAD-affected vessels usually heal without intervention. Randomized clinical trials and other prospective evaluations are needed, especially to clarify optimal treatment and prevention strategies.

Resistance exercise for cardiac rehabilitation

Lean mass abnormalities are highly prevalent in patients referred for cardiac rehabilitation (CR). As such, current guidelines recommend incorporating resistance exercise (RE) into the exercise prescription of Phase II-IV CR. The effects of RE on health-related outcomes in patients with cardiovascular (CV) disease (CVD) have not been extensively investigated in comparison to aerobic exercise, the traditional modality of exercise implemented in CR. The purpose of this review is to highlight the growing prevalence of lean mass abnormalities such as dynapenia and sarcopenia in CVD and briefly outline the contributing pathophysiology of these impairments as potential targets for RE training. An update on the current evidence pertaining to the effects of RE on exercise capacity, skeletal muscle strength, body composition, CV health, and quality of life in CR patient populations is provided. The current recommendations for RE training in CR are discussed. Future directions for research and clinical practice in this field are highlighted, and included the need to identify the most efficacious principles of resistance training for different health related outcomes in CVD, as well as the suggested drive towards a 'personalized medicine' approach to exercise prescription in CR.

Cardiac rehabilitation following coronary artery dissection: recommendations and patient considerations

INTRODUCTION

: Cardiac rehabilitation (CR) is a multidisciplinary intervention for secondary prevention, improving functional capacity, enhancing quality of life, and improving psychosocial wellbeing in broad range of cardiovascular disease. It has been well studied over a number of years and is a Class I recommendation in multiple guidelines. However, there is a paucity of data regarding the usefulness of CR in patients with spontaneous coronary artery dissection (SCAD).

AREAS COVERED

: This narrative review aims to give an overview of the evidence underpinning CR as well as the pathophysiological mechanisms of SCAD and how they relate to exercise and shear stress. Furthermore, the evidence of the usefulness of CR in the SCAD population will be reviewed.

EXPERT OPINION

: Traditional CR programs are safe and effective in SCAD cohorts, however SCAD specific CR (SCAD-CR) has significant benefits including reductions in MACE. The principles of SCAD-CR should be applied to any CR for SCAD patients for optimal outcomes and minimization of harm.

Spontaneous Coronary Artery Dissection: A Rare Event?

Spontaneous coronary artery dissection is an infrequent cause of acute coronary syndrome with comparable clinical features. Previously considered a rare disease, recent scientific interest has revealed spontaneous coronary artery dissection as an important differential diagnosis of acute coronary syndrome, especially in young women, during pregnancy or postpartum, and in patients with fibromuscular dysplasia or other arteriopathies. However, there remain many uncertainties regarding pathophysiology, risk factors, acute treatment, and optimal long-term management. The aim of this review is to summarize current scientific evidence on epidemiology, management, and outcomes.

Rethinking Rehabilitation: A REVIEW OF PATIENT POPULATIONS WHO CAN BENEFIT FROM CARDIAC REHABILITATION

Although cardiac rehabilitation (CR) is safe and highly effective for individuals with various cardiovascular health conditions, to date there are only seven diagnoses or procedures identified by the Centers for Medicare & Medicaid Services that qualify for referral. When considering the growing number of individuals with cardiovascular disease (CVD), or other health conditions that increase the risk for CVD, it is important to determine the extent for which CR could benefit these populations. Furthermore, there are some patients who may currently be eligible for CR (spontaneous coronary artery dissection, left ventricular assistant device) but make up a relatively small proportion of the populations that are regularly attending and participating. Thus, these patient populations and special considerations for exercise might be less familiar to professionals who are supervising their programs. The purpose of this review is to summarize the current literature surrounding exercise testing and programming among four specific patient populations that either do not currently qualify for (chronic and end-stage renal disease, breast cancer survivor) or who are eligible but less commonly seen in CR (sudden coronary artery dissection, left ventricular assist device). While current evidence suggests that individuals with these health conditions can safely participate in and may benefit from supervised exercise programming, there is an immediate need for high-quality, multisite clinical trials to develop more specific exercise recommendations and support the inclusion of these populations in future CR programs.

Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS

PURPOSE

Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR.

REVIEW METHODS

The review examines original studies and meta-analyses regarding women in CR.

SUMMARY

Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR.

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.

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection is an underdiagnosed entity. It has been recognized as an important cause of acute coronary syndrome and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. This document provides an exhaustive review of the pathophysiology and etiology of this disease. In addition, we describe the main clinical characteristics of these patients, the diagnostic tests that must be performed, and the most appropriate treatment.

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection is an underdiagnosed entity. It has been recognized as an important cause of acute coronary syndrome and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. This document provides an exhaustive review of the pathophysiology and etiology of this disease. In addition, we describe the main clinical characteristics of these patients, the diagnostic tests that must be performed, and the most appropriate treatment.

Recurrent spontaneous coronary artery dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a cause of non-atherosclerotic acute coronary syndrome and sudden cardiac death that predominantly impacts young and middle-aged women. In addition to the challenges of acute SCAD including arrhythmias, heart failure, and recurrent chest pain, de novo recurrent SCAD occurs in 5-29% of patients. Recurrent SCAD presents both a psychological burden and a significant cardiac risk to patients. Research regarding SCAD recurrence risk has been growing and can guide providers and patients alike.Areas covered: This review provides up-to-date information about many aspects of SCAD with a focus on SCAD recurrence. PubMed articles were reviewed through October 2020, with particular focus on clinical studies and original research. The resulting literature was scrutinized for information on SCAD recurrence. SCAD-associated conditions, genetic data, clinical characteristics, medications, and aspects of post-SCAD care are summarized.Expert Opinion: SCAD recurrence poses a concerning risk for patients with SCAD. Conditions such as hypertension and severe coronary tortuosity may be associated with recurrence. More research is needed to further elucidate risk factors for recurrence and clarify interventions, such as beta blocker therapy, that may reduce recurrence risk.

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.

Psychological and clinical characteristics of patients with spontaneous coronary artery dissection: A case-control study

BACKGROUND

The relative frequency of psychological factors in patients with spontaneous coronary artery dissection (SCAD) compared to patients with traditional atherosclerosis-related type 1 acute coronary syndrome (ACS) is unknown. This study examines whether psychological factors and emotional or physical precipitants are more common in SCAD patients versus atherosclerosis-related ACS patients.

METHODS

Participants with SCAD were recruited from a Dutch SCAD database. Given the predominance of SCAD in women (>90%), only female patients were included. The age- and sex-matched atherosclerosis-related ACS group was identified from a registry database. Online questionnaires and medical records were used to investigate psychological factors and clinical information. Univariate and multivariate logistic regression models were used to examine differences between 172 SCAD patients and 76 ACS patients on emotional and physical precipitants prior to the event and psychological factors after the event.

RESULTS

Patients with SCAD were more likely to experience an emotional precipitant in the 24 h prior to the event (56%), compared with the ACS group (39%) (OR = 1.98, 95%CI 1.14-3.44). Multivariate analyses showed that this association remained significant after adjustment for covariates (OR = 2.17, 95%CI 1.08-4.36). At an average of 3.2 years post-hospitalization for the SCAD or atherosclerosis-related ACS event, both patient groups had similar high levels of perceived stress (50% vs. 45%, p = .471) and fatigue (56% vs. 53%, p = .643).

CONCLUSIONS

This study shows that risk profiles for SCAD differ from traditional atherosclerosis-related ACS. Our findings may help health professionals to recognize SCAD and offer tailored rehabilitation and prevention programs.

Analysis of Posttraumatic Stress Disorder, Depression, Anxiety, and Resiliency Within the Unique Population of Spontaneous Coronary Artery Dissection Survivors

Background

Mental health after spontaneous coronary artery dissection (SCAD), a cause of myocardial infarction in young women, remains largely unexplored. We assessed the prevalence and severity of psychiatric symptoms after SCAD.

Methods and Results

Individuals with confirmed SCAD who consented to the Mayo Clinic “Virtual” Multicenter SCAD Registry were sent the Posttraumatic Stress Disorder Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Patient Health Questionnaire‐9, Generalized Anxiety Disorder‐7, Anxiety Sensitivity Index, Connor‐Davidson Resilience Scale, 36‐Item Short‐Form Health Survey, and an SCAD‐specific questionnaire. Among 782 patients contacted, 512 surveys were returned. Most respondents were women (97.5%), with median age at time of SCAD and survey completion of 47 and 52 years, respectively. Eighty‐two percent had at least one trauma, with mild or more posttraumatic stress disorder symptoms in 28%. Symptoms of anxiety and depression were observed in 41% and 32%, respectively. On multivariable analysis, those of younger age at first SCAD and low resiliency scored higher on measures of trauma, anxiety, and depression. Those with higher anxiety sensitivity had more severe anxiety and posttraumatic stress disorder symptoms. Emotional and social quality of life was higher in those with high resiliency scores. Time from SCAD event to survey completion was associated with lower Generalized Anxiety Disorder‐7 score severity.

Conclusions

Survivors of SCAD have significant rates of posttraumatic stress disorder, depression, and anxiety, which are associated with lower quality of life specifically among those with lower resiliency. Given the prevalence and potential impact, screening and treatment for the psychological distress is advised. Behavioral interventions targeted toward resiliency training may be beneficial for this patient population.

Spontaneous Coronary Artery Dissection: Mechanisms, Diagnosis and Management

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome that usually affects young to middle-aged women. Mainly because of its low prevalence, until recently, most of the evidence on this condition was derived from case reports and small series. Over the last 5 years, more robust evidence has become available from larger retrospective and prospective cohorts of patients with SCAD. The increase in knowledge and recognition of this entity has led to the publication of expert consensus on both sides of the Atlantic. However, new data are continuously accumulating from larger cohorts of patients with SCAD, bringing new light to this little-understood condition. The aim of this article is to update the knowledge on SCAD, including new information from recent studies published since the consensus documents from the European Society of Cardiology and the American Heart Association.

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.

Spontaneous coronary artery dissection: etiology and recurrence

Introduction: Spontaneous coronary artery dissection (SCAD) is an increasingly appreciated cause of acute myocardial infarction (AMI) and sudden cardiac death most often affecting young to middle-aged women with few conventional cardiovascular risk factors. Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 04/30/2019). Authors review the key clinical features of SCAD and highlight what is known regarding its pathophysiology and associated factors. The relationship between SCAD and other systemic vasculopathies, notably fibromuscular dysplasia (FMD) is also discussed. Authors also mention the management of acute SCAD along with considerations for long term follow-up such as chest pain syndrome, extracoronary vasculopathy screening, and recurrent SCAD. Expert opinion: Our understanding regarding the association of SCAD and other arteriopathies such as FMD is anticipated to grow. In addition, progress is likely to be made in our efforts to predict recurrent SCAD risk and define potential preventative strategies, possibly through the incorporation of adjunctive imaging.

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.

Conditions and Factors Associated With Spontaneous Coronary Artery Dissection (from a National Population-Based Cohort Study)

The pathophysiology of spontaneous coronary artery dissection (SCAD) is heterogeneous, associated with systemic arteriopathies and inflammatory diseases, and often compounded by environmental precipitants, genetics, or stressors. However, the frequency of these associated conditions with SCAD on a population level remains unknown. Therefore, the objective of this analysis was to evaluate heterogeneous phenotypes of SCAD in the United States using data from the Nationwide Inpatient Sample collected from January 1, 2004, to September 31, 2015. Among 66,360 patients diagnosed with SCAD, the mean age was 63.1 ± 13.2 years and 44.2% were women. A total of 3,415 (5.14%) had depression, 670 (1.0%) had rheumatoid arthritis, 640 (0.96%) had anxiety, 545 (0.82%) had a migraine disorder, 440 (0.66%) used steroids, 385 (0.58%) had malignant hypertension, 280 (0.42%) had systemic lupus erythematosus, 250 (0.38%) had cocaine abuse, 215 (0.32%) had hypertensive heart or renal disease, 130 (0.19%) had coronary spasm, 105 (0.16%) had fibromuscular dysplasia, 85 (0.13%) had Crohn's disease, 75 (0.11%) had celiac disease, 60 (0.09%) had adult autosomal dominant polycystic kidney disease, 60 (0.09%) had hormone replacement therapy, 55 (0.08%) had sarcoidosis, 55 (0.08%) had amphetamine abuse, 15 (0.02%) had granulomatosis polyangiitis, 10 (0.02%) had α1-antitrypsin deficiency, 10 (0.02%) had Marfan syndrome, 10 (0.02%) had Ehlers-Danlos syndrome, 10 (0.02%) had Kawasaki disease, 10 (0.02%) had polyarteritis nodosa, and 5 (0.01%) had multiparity. In conclusion, most cases of SCAD had no apparent concomitant arteriopathy, inflammatory disorder, or evident risk factor.

Trends in Incidence, Characteristics, and In-Hospital Outcomes of Patients Presenting With Spontaneous Coronary Artery Dissection (From a National Population-Based Cohort Study Between 2004 and 2015)

Though infrequent, spontaneous coronary artery dissection (SCAD) is increasingly recognized as an important cause of acute coronary syndrome (ACS), particularly in young healthy women. However, the population-based incidence of SCAD is unknown. We evaluated the incidence, patient characteristics, clinical characteristics, and mortality of SCAD-related hospitalizations using data from a national population-based cohort study from January 1, 2004, to September 30, 2015. In 13,573,200 patients who presented with an acute coronary syndrome, 66,360 (0.49%) of patients were diagnosed with SCAD. The mean age was 63.1 ± 13.2 years and 44.2% were women. In-hospital mortality of SCAD patients was 4.2%: 5.03% in females and 3.55% in males (p < 0.001). In conclusion, SCAD is an uncommon diagnosis that should be considered in males and older patients in addition to females presenting with ACS. Most SCAD patients today are managed medically. In-hospital mortality is comparable to that of other patients who present with ACS.

Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management

Spontaneous coronary artery dissection is an increasingly recognised cause of acute coronary syndromes, especially in young and middle-age women. Recognising its particularities and differences with atherosclerotic disease is central for appropriately identifying and approaching these patients. The authors review the current state of knowledge on spontaneous coronary artery dissection and provide practical recommendations for the diagnosis and management of this condition, both in the acute and convalescence phases.

Spontaneous coronary artery dissection: from expert consensus statements to evidence-based medicine

Spontaneous coronary artery dissection (SCAD) represents an increasingly recognized cause of acute coronary syndrome (ACS), especially in young females. Novel diagnostic insights obtained from intracoronary imaging and the frequent association with fibromuscular dysplasia (FMD), have recently enriched our understanding of this unique clinical entity. Recently, two scientific statements from both sides of the Atlantic, summarizing the available information on SCAD, have been simultaneously published. These should help to guide the clinical management of these challenging patients. Major collaborative research efforts are required to move from expert-based recommendations to evidence-based [corrected] medicine.

Pregnancy-Associated Myocardial Infarction

PURPOSE OF REVIEW

To educate clinicians about the epidemiology, etiologies, diagnosis, and management of pregnancy-associated myocardial infarction (PAMI).

RECENT FINDINGS

The risk of myocardial infarction is increased more than threefold around the time of pregnancy. In the recent series, PAMI is most commonly caused by spontaneous coronary artery dissection, followed by atherosclerosis. Percutaneous coronary intervention or coronary artery bypass grafting may be required, but conservative management with medical therapy is generally advised when possible, particularly in cases of coronary dissection. Labor and delivery in women with PAMI warrants advanced planning by a multidisciplinary team involving obstetrics, anesthesia, and cardiology. Women with myocardial infarction should be referred to cardiac rehabilitation. Pregnancy-associated myocardial infarction is a significant contributor to maternal morbidity and mortality. Management should be tailored based on the underlying etiology and on whether the patient is still pregnant or postpartum. Further research is needed to define optimal evaluation and management of this condition.

Acute myocardial infarction in young women: current perspectives

Acute myocardial infarction (AMI) is the leading cause of death in women worldwide. Every year, in the USA alone, more than 30,000 young women <55 years of age are hospitalized with AMI. In recent decades, the incidence of AMI is increasing in younger women in the context of increasing metabolic syndrome, diabetes mellitus, and non-traditional risk factors such as stress, anxiety, and depression. Although women are classically considered to present with atypical chest pain, several observational data confirm that men and women experience similar rates of chest pain, with some differences in intensity, duration, radiation, and the choice of descriptors. Women also experience more number of symptoms and more prodromal symptoms compared with men. Suboptimal awareness, sociocultural and financial reasons result in pre-hospital delays in women and lower rates of access to care with resulting undertreatment with guideline-directed therapies. Causes of AMI in young women include plaque-related MI, microvascular dysfunction or vasospasm, and spontaneous coronary artery dissection. Compared with men, women have greater in-hospital, early and late mortality, as a result of baseline comorbidities. Post-AMI women have lower referral to cardiac rehabilitation with more dropouts, lower levels of physical activity, and poorer improvements in health status compared with men, with higher inflammatory levels at 1-year from index presentation. Future strategies should focus on primary and secondary prevention, adherence, and post-AMI health-related quality of life. This review discusses the current evidence in the epidemiology, diagnosis, and treatment of AMI in young women.