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Stanojevic D, Apostolovic S, Kostic T, Mitov V, Kutlesic-Kurtovic D, Kovacevic M, Stanojevic J, Milutinovic S, Beleslin B. A review of the risk and precipitating factors for spontaneous coronary artery dissection. Front Cardiovasc Med 2023; 10:1273301. [PMID: 38169687 PMCID: PMC10758453 DOI: 10.3389/fcvm.2023.1273301] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction Spontaneous coronary artery dissection (SCAD) accounts for 1%-4% of cases of acute coronary syndrome (ACS). SCAD is caused by separation occurring within or between any of the three tunics of the coronary artery wall. This leads to intramural hematoma and/or formation of false lumen in the artery, which leads to ischemic changes or infarction of the myocardium. The incidence of SCAD is higher in women than in men, with a ratio of approximately 9:1. It is estimated that SCAD is responsible for 35% of ACS cases in women under the age of 60. The high frequency is particularly observed during pregnancy and in the peripartum period (first week). Traditional risk factors are rare in patients with SCAD, except for hypertension. Patients diagnosed with SCAD have different combinations of risk factors compared with patients who have atherosclerotic changes in their coronary arteries. We presented the most common so-called "non-traditional" risk factors associated with SCAD patients. Risk factors and precipitating disorders which are associated with SCAD In the literature, there are few diseases frequently associated with SCAD, and they are identified as predisposing factors. The predominant cause is fibromuscular dysplasia, followed by inherited connective tissue disorders, systemic inflammatory diseases, pregnancy, use of sex hormones or steroids, use of cocaine or amphetamines, thyroid disorders, migraine, and tinnitus. In recent years, the genetic predisposition for SCAD is also recognized as a predisposing factor. The precipitating factors are also different in women (emotional stress) compared with those in men (physical stress). Women experiencing SCAD frequently describe symptoms of anxiety and depression. These conditions could increase shear stress on the arterial wall and dissection of the coronary artery wall. Despite the advancement of SCAD, we can find significant differences in the clinical presentation between women and men. Conclusion When evaluating patients with chest pain or other ACS symptoms who have a low cardiovascular risk, particularly female patients, it is important to consider the possibility of ACS due to SCAD, particularly in conditions often associated with SCAD. This will increase the recognition of SCAD and the timely treatment of affected patients.
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Affiliation(s)
| | - Svetlana Apostolovic
- Clinic for Cardiology, University Clinical Center Nis, Nis, Serbia
- Internal Medicine Department, Medical Faculty University of Nis, Nis, Serbia
| | - Tomislav Kostic
- Clinic for Cardiology, University Clinical Center Nis, Nis, Serbia
- Internal Medicine Department, Medical Faculty University of Nis, Nis, Serbia
| | - Vladimir Mitov
- Department for Cardiovascular Diseases, Health Center Zajecar, Zajecar, Serbia
| | | | - Mila Kovacevic
- Clinic for Cardiology, Institute for Cardiovascular Diseases Vojvodina, Novi Sad, Serbia
- Internal Medicine Department, Medical Faculty University of Novi Sad, Novi Sad, Serbia
| | - Jelena Stanojevic
- Internal Medicine Department, Medical Faculty University of Nis, Nis, Serbia
| | - Stefan Milutinovic
- Internal Medicine Residency Program, Florida State University College of Medicine, Cape Coral, FL, United States
| | - Branko Beleslin
- Clinic for Cardiology, University Clinical Centre Serbia, Belgrade, Serbia
- Internal Medicine Department, Medical Faculty Belgrade, Belgrade, Serbia
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Kim ESH, Saw J, Kadian-Dodov D, Wood M, Ganesh SK. FMD and SCAD: Sex-Biased Arterial Diseases With Clinical and Genetic Pleiotropy. Circ Res 2021; 128:1958-1972. [PMID: 34110898 DOI: 10.1161/circresaha.121.318300] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Multifocal fibromuscular dysplasia (FMD) and spontaneous coronary artery dissection are both sex-biased diseases disproportionately affecting women over men in a 9:1 ratio. Traditionally known in the context of renovascular hypertension, recent advances in knowledge about FMD have demonstrated that FMD is a systemic arteriopathy presenting as arterial stenosis, aneurysm, and dissection in virtually any arterial bed. FMD is also characterized by major cardiovascular presentations including hypertension, stroke, and myocardial infarction. Similar to FMD, spontaneous coronary artery dissection is associated with a high prevalence of extracoronary vascular abnormalities, including FMD, aneurysm, and extracoronary dissection, and recent studies have also found genetic associations between the two diseases. This review will summarize the relationship between FMD and spontaneous coronary artery dissection with a focus on common clinical associations, histopathologic mechanisms, genetic susceptibilities, and the biology of these diseases. The current status of disease models and critical future research directions will also be addressed.
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Affiliation(s)
- Esther S H Kim
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (E.S.H.K.)
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia Canada (J.S.)
| | - Daniella Kadian-Dodov
- Zena and Michael A. Wiener Cardiovascular Institute, Marie-Joseé and Henry R. Kravis Center for Cardiovascular Health, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY (D.K.-D.)
| | - Malissa Wood
- Division of Cardiology, Harvard Medical School, Massachusetts General Hospital, Boston (M.W.)
| | - Santhi K Ganesh
- Division of Cardiovascular Medicine, Department of Internal Medicine (S.K.G.), University of Michigan Medical School, Ann Arbor.,Department of Human Genetics (S.K.G.), University of Michigan Medical School, Ann Arbor
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Shah KP, Peruri A, Kanneganti M, Gorsch L, Ramcharitar R, Williams C, Clouse D, Thomas M, Norton PT, Hagspiel KD, Taylor A, Southerland A, Matsumoto AH, Angle JF, Mace P, Khaja MS, Sharma AM. Fibromuscular dysplasia: A comprehensive review on evaluation and management and role for multidisciplinary comprehensive care and patient input model. Semin Vasc Surg 2021; 34:89-96. [PMID: 33757641 DOI: 10.1053/j.semvascsurg.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Fibromuscular dysplasia is a nonatherosclerotic, under-recognized disorder primarily seen in middle-aged women. It can lead to several complications, such as hypertension, headaches, dissections, aneurysms, myocardial infarctions, and cerebrovascular accidents, to name a few. This article provides a comprehensive review of current literature on epidemiology, etiology, diagnosis, treatment, and long-term surveillance and fibromuscular dysplasia management. In addition, it renders the role of education and prevention for patients living with this condition and family screening. Lastly, it emphasizes the importance of a comprehensive multidisciplinary care model and patient input, given the complexity of this disease and its systemic presence and protean manifestations.
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Affiliation(s)
- Kajal P Shah
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | - Adithya Peruri
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | | | - Lindsey Gorsch
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | - Randy Ramcharitar
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | - Carlin Williams
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Darrin Clouse
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Matthew Thomas
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Patrick T Norton
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Klaus D Hagspiel
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Angela Taylor
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908
| | | | - Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - John F Angle
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Pamela Mace
- Executive Director, Fibromuscular Dysplasia Society for America, North Olmsted, OH
| | - Minhaj S Khaja
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Aditya M Sharma
- Department of Medicine, University of Virginia, PO Box 100058, 1215 Lee Street, Charlottesville, VA 22908.
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Affiliation(s)
- Esther S H Kim
- From the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville
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Tweet MS, Young KA, Best PJM, Hyun M, Gulati R, Rose CH, Hayes SN. Association of Pregnancy With Recurrence of Spontaneous Coronary Artery Dissection Among Women With Prior Coronary Artery Dissection. JAMA Netw Open 2020; 3:e2018170. [PMID: 32965500 PMCID: PMC7512056 DOI: 10.1001/jamanetworkopen.2020.18170] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Spontaneous coronary artery dissection (SCAD) is a notable cause of acute coronary syndrome in women of childbearing age. OBJECTIVE To test the hypothesis that pregnancy after SCAD is associated with recurrent SCAD. DESIGN, SETTING, AND PARTICIPANTS Three study designs were implemented: a case series of women with pregnancy after SCAD; a nested case-control study comparing patients with recurrent SCAD to matched controls without recurrent SCAD; and a cohort study. Women with SCAD who were of childbearing potential and enrolled into the Mayo Clinic SCAD Registry from August 30, 2011, to April 4, 2019, were included in the study. Patients with coronary dissections associated with iatrogenesis, trauma, or atherosclerosis were not enrolled. EXPOSURES Pregnancy after SCAD. MAIN OUTCOMES AND MEASURES The primary outcome was SCAD recurrence, defined as an acute coronary syndrome or cardiac arrest due to new SCAD. Other demographic measures collected included age, year of SCAD occurrence, and comorbidities. RESULTS The cohort included 636 women of childbearing potential. Twenty-three of those women had a total of 32 pregnancies after SCAD. The median (interquartile range) age of women with pregnancy after SCAD was 38 years (34-40 years), and 20 (87%) were White. In the nested case-control study, 92 cases of recurrent SCAD were matched to 158 controls. There was no significant difference in exposure to subsequent pregnancies in the women with recurrent SCAD as compared with matched controls (2 of 92 [2%] vs 13 of 158 [8%]; P = .06). In the overall cohort of 636 patients, recurrent SCAD was present in 122 patients with a Kaplan-Meier 5-year SCAD recurrence estimate of 14.8%. The Cox analysis showed no significant association between subsequent pregnancy and SCAD recurrence with a nonsignificant hazard ratio of 0.38 (95% CI, 0.09-1.6) when controlling for age at first SCAD, year of first SCAD, and fibromuscular dysplasia. CONCLUSIONS AND RELEVANCE This study found that most women tolerated pregnancy and lactation after SCAD without evidence for increased risk of SCAD recurrence when compared with women with a history of SCAD who did not experience pregnancy. Although this study is reassuring and indicates complex contributors to SCAD recurrence, the results need to be interpreted prudently because of study selection bias and the small total number of women who became pregnant after SCAD. The notable hemodynamic changes that occur with pregnancy and severe presentation of pregnancy-associated SCAD are reasons for concern when considering pregnancy after SCAD.
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Affiliation(s)
- Marysia S. Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kathleen A. Young
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Patricia J. M. Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Meredith Hyun
- Department of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Carl H. Rose
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Sharonne N. Hayes
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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