Spontaneous coronary artery dissection: a review of complications and management strategies

Spontaneous coronary artery dissection: A review of medical management approaches

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome (ACS) that usually presents in young female patients. Risk factors include female sex, physical and emotional stressors, and fibromuscular dysplasia, and diagnosis is usually made by coronary angiography aided by intravascular ultrasound (IVUS) or optical coherence tomography (OCT). While conservative treatment is usually preferred over percutaneous coronary intervention or surgery, medical management of SCAD has been under debate. This comprehensive review aims to summarize findings from recent studies exploring various medical treatment approaches for the management of SCAD. Antiplatelet therapy with aspirin is generally safe and beneficial for SCAD patients, with dual antiplatelet (DAPT) being recommended for patients undergoing PCI. In the absence of intervention, DAPT may be given for a short period followed by a longer single-antiplatelet (SAPT) therapy with aspirin. Beta-blockers appear to be safe and effective for SCAD patients. On the other hand, fibrinolytics, anticoagulants, and glycoprotein IIa/IIIb inhibitors are contraindicated. Cardiovascular medications such as renin-angiotensin-aldosterone system (RAAS) inhibitors, mineralocorticoid receptor antagonists, and statins are not recommended in the absence of left ventricular dysfunction. Hormonal therapy is contraindicated for patients who develop SCAD during pregnancy and future pregnancy is discouraged in that patient population.

Iatrogenic Massive Coronary Artery Dissection During Cardiac Catheterization: A Case Report

Cardiac catheterization is an invasive procedure done for diagnostic and therapeutic purposes to assess coronary artery disease (CAD) and valvular diseases. Although complications rarely occur, they are possible. Of those complications, iatrogenic coronary artery dissection during a coronary catheterization is infrequent and can be severe. This case report discusses a 59-year-old female presenting to the emergency department for sudden onset chest pain, found to have a non-ST-elevation myocardial infarction (NSTEMI), and underwent a left heart catheterization (LHC). During the LHC, she sustained a coronary artery dissection.

Spontaneous coronary artery dissection in women in the generative period: clinical characteristics, treatment, and outcome-a systematic review and meta-analysis

Introduction

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall.

Materials and methods

This systematic review and meta-analysis is reported following the PRISMA guidelines and is registered in the PROSPERO database. A literature search was focused on female patients in generative period (16-55 of age) with acute coronary syndrome (ACS) caused by SCAD, and comparison from that database NP-SCAD (spontaneous coronary artery dissection in non pregnant women) and P-SCAD (spontaneous coronary artery dissection in pregnant women).

Results

14 studies with 2,145 females in the generative period with ACS caused by SCAD were analyzed. The median age was 41 years (33.4-52.3 years). The most common risk factor was previous smoking history in 24.9% cases. The most common clinical presentation of ACS was STEMI in 47.4%. Conservative treatment was reported in 41.1%. PCI was performed in 32.7%, and 3.8% of patients had CABG surgery. LAD was the most frequently affected (50.5%). The prevalence of composite clinical outcomes including mortality, non-fatal MI and recurrent SCAD was 3.3% (95% CI: 1.4-5.1), 37.7% (95% CI: 1.9-73.4) and 15.2% (95% CI: 9.1-21.3) of patients. P-SCAD compared to NP-SCAD patients more frequently had STEMI (OR = 3.16; 95% CI: 2.30-4.34; I2 = 64%); with the left main and LAD more frequently affected [(OR = 14.34; 95% CI: 7.71-26.67; I2 = 54%) and (OR = 1.57; 95% CI: 1.06-2.32; I2 = 23%)]; P-SCAD patients more frequently underwent CABG surgery (OR = 6.29; 95% CI: 4.08-9.70; I2 = 0%). NP-SCAD compared to P-SCAD patients were more frequently treated conservatevly (OR = 0.61; 95% CI: 0.37-0.98; I2 = 0%). In P-SCAD compared to NP-SCAD mortality rates (OR = 1.13; 95% CI: 0.06-21.16; I2 = not applicable) and reccurence of coronary artery dissection (OR = 2.54; 95% CI: 0.97-6.61; I2 = 0%) were not more prevalent.

Conclusion

The results of this meta-analysis indicated that patients with P-SCAD more frequently had STEMI, and events more frequently involved left main and LAD compared to NP-SCAD patients. Women with NP-SCAD were significantly more often treated conservatively compared to P-SCAD patients. P-SCAD compared to NP-SCAD patients did not have significantly higher mortality rates or recurrent coronary dissection.

Psychosocial and lifestyle impacts of spontaneous coronary artery dissection: A quantitative study

INTRODUCTION

Recent studies suggest that acute myocardial infarction due to spontaneous coronary artery dissection (SCAD) carries significant psychosocial burden. This survey-based quantitative study builds on our earlier qualitative investigation of the psychosocial impacts of SCAD in Australian SCAD survivors. The study aimed to document the prevalence and predictors of a broad range of psychosocial and lifestyle impacts of SCAD.

METHOD

Australian SCAD survivors currently enrolled in the Victor Chang Cardiac Research Institute genetics study were invited to participate in an online survey to assess the psychosocial impacts of SCAD. Participants completed a questionnaire, developed using findings from our earlier qualitative research, which assessed 48 psychosocial and five lifestyle impacts of SCAD. Participants also provided demographic and medical data and completed validated measures of anxiety and depression.

RESULTS

Of 433 SCAD survivors invited to participate, 310 (72%) completed the questionnaire. The most common psychosocial impacts were 'shock about having a heart attack' (experienced by 87% respondents), 'worry about having another SCAD' (81%), 'concern about triggering another SCAD' (77%), 'uncertainty about exercise and physical activity' (73%) and 'confusion about safe levels of activity and exertion' (73.0%) and 'being overly aware of bodily sensations' (73%). In terms of lifestyle impacts, the SCAD had impacted on work capacity for almost two thirds of participants, while one in ten had sought financial assistance. The key predictors of psychosocial impacts were being under 50, current financial strain, and trade-level education. The key predictors of lifestyle impacts were being over 50, SCAD recurrence, trade-level education, and current financial strain. All psychosocial impacts and some lifestyle impacts were associated with increased risk of anxiety and/or depression.

CONCLUSION AND IMPLICATIONS

This quantitative study extends our previous qualitative investigation by documenting the prevalence of each of 48 psychosocial and five lifestyle impacts identified in our earlier focus group research, and by providing risk factors for greater SCAD impacts. The findings suggest the need for supports to address initial experiences of shock, as well as fears and uncertainties regarding the future, including SCAD recurrence and exercise resumption. Support could be targeted to those with identified risk factors. Strategies to enable SCAD survivors to remain in or return to the paid workforce are also indicated.

Prevalence of Anxiety, Depression, and Distress in SCAD and Non-SCAD AMI Patients: A Comparative Study

PURPOSE

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute myocardial infarction (AMI), particularly in younger women without classic cardiac risk factors. Spontaneous coronary artery dissection is considered to be particularly stressful; however, few studies have quantified SCAD survivor stress levels. This study compared anxiety, depression, and distress levels in SCAD and non-SCAD AMI patients.

METHOD

A sample of 162 AMI (35 [22%] SCAD) patients was recruited from hospitals and via social media, in Australia and the United States. All had had their AMI in the past 6 mo. Participants completed an online questionnaire comprising the Generalized Anxiety Disorder-2 (GAD2), Patient Health Questionnaire-2 (PHQ2), Kessler-6 (K6), and Cardiac Distress Inventory (CDI). T-tests, χ 2 tests, Mann-Whitney tests, and analysis of covariance were used to compare SCAD and non-SCAD samples. Logistic regression was used to identify the unique predictors of anxiety, depression, and distress, controlling for relevant confounders.

RESULTS

Patients with SCAD were more commonly female and significantly younger than non-SCAD patients. Patients with SCAD scored significantly higher on the GAD2, PHQ2, K6, and CDI and a significantly larger proportion was classified as anxious, depressed, or distressed using these instruments. In logistic regression, together with mental health history, having had a SCAD-AMI predicted anxiety, depression, and distress, after controlling for female sex, younger age, and other confounding variables.

CONCLUSION

This study supports the view that anxiety, depression, and distress are more common after SCAD-AMI than after traditional AMI. These findings highlight the psychosocial impacts of SCAD and suggest that psychological support should be an important component of cardiac rehabilitation for these patients.

Spontaneous Coronary Artery Dissection: A Literature Review

Spontaneous coronary artery dissection is a medical condition characterized by the rupture of the coronary artery wall, occurring without any external trauma. This ailment has been linked to various inflammatory, rheumatologic, and connective tissue disorders, as well as pregnancy-related changes. Despite being a less familiar cause of acute coronary syndrome, it has a considerable mortality rate, with incidence rates reaching up to 4%. This review will discuss the occurrence, pathophysiology, categorization, risk factors, diagnostic techniques, and treatment approaches related to spontaneous coronary artery dissection.

Unmasking the Silent Intruder: A Case of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection continues to pose a diagnostic dilemma in the evaluation of patients with chest pain. Our case discusses its manifestation in a male patient who visited the emergency department complaining of recent-onset chest pain. Evaluation of his chest pain through coronary angiography revealed luminal radiolucency corresponding to type 1 spontaneous coronary artery dissection (SCAD). The patient was promptly managed using medical interventions until stability was achieved and referred to cardiac rehabilitation care with close follow-up. In our literary contribution, we present a fascinating diagnosis, potentially life-threatening, observed in an otherwise active and healthy male patient. Notably, this diagnosis is uncommon in the male population. Through this study, we aimed to shed light on understanding, awareness, and clinical recognition of SCAD, ultimately improving patient care and outcomes.

Genetics of spontaneous cervical and coronary artery dissections

Objectives

Spontaneous cervical artery dissections (SCeAD) and coronary artery dissections (SCoAD) are major causes of neurovascular and cardiovascular morbidity in young adults. Although multiple aspects of their etiology are still unknown, most consensuses are focused on the presence of constitutional genetic aspects and environmental triggers. Since recent evidence of genetic contribution points to a possible overlap between these conditions, we aimed to describe current information on SCeAD and SCoAD genetics and their potential shared pathological aspects.

Materials and methods

A narrative review is presented. Publications in English and Spanish were queried using database search. The articles were evaluated by one team member in terms of inclusion criteria. After collecting, the articles were categorized based on scientific content.

Results

Given that patients with SCeAD and SCoAD rarely present connective tissue disorders, other genetic loci are probably responsible for the increased susceptibility in some individuals. The common variant rs9349379 at PHACTR1 gene is associated with predisposition to pathologies of the arterial wall, likely mediated by variations in Endothelin-1 (ET-1) levels. The risk of arterial dissection may be increased for those who carry the rs9349379(A) allele, associated with lower expression levels of ET-1; however, the local effect of this vasomotor imbalance remains unclear. Sex differences seen in SCeAD and SCoAD support a role for sex hormones that could modulate risk, tilting the delicate balance and forcing vasodilator actions to prevail over vasoconstriction due to a reduction in ET-1 expression.

Conclusions

New evidence points to a common gene variation that could explain dissection in both the cervical and coronary vasculatures. To further confirm the risk conferred by the rs9349379 variant, genome wide association studies are warranted, hopefully in larger and ethnically diverse populations.

Contemporary Diagnosis and Management of Patients with MINOCA

PURPOSE OF REVIEW

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is defined as acute myocardial infarction (MI) with angiographically no obstructive coronary artery disease or stenosis ≤ 50%. MINOCA is diagnostically challenging and complex, making it difficult to manage effectively. This condition accounts for 6-8% of all MI and poses an increased risk of morbidity and mortality after diagnosis. Prompt recognition and targeted management are essential to improve outcomes and our understanding of this condition, but this process is not yet standardized. This article offers a comprehensive review of MINOCA, delving deep into its unique clinical profile, invasive and noninvasive diagnostic strategies for evaluating MINOCA in light of the lack of widespread availability for comprehensive testing, and current evidence surrounding targeted therapies for patients with MINOCA.

RECENT FINDINGS

MINOCA is not uncommon and requires comprehensive assessment using various imaging modalities to evaluate it further. MINOCA is a heterogenous working diagnosis that requires thoughtful approach to diagnose the underlying disease responsible for MINOCA further.

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.

Spontaneous coronary artery dissection: A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic, non-traumatic separation of the coronary artery wall. The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors. SCAD is frequently linked with predisposing factors, such as postpartum, fibromuscular dysplasia or other vasculopathies, connective tissue disease and hormonal therapy, and it is often triggered by intense physical or emotional stress, sympathomimetic drugs, childbirth and activities increasing shear stress of the coronary artery walls. Patients with SCAD usually present at the emergency department with chest discomfort, chest pain, and rapid heartbeat or fluttery. During the last decades, the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis. However, modern imaging techniques such as optical coherence tomography, intravascular ultrasound, coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease. Treatment of SCAD remains controversial, especially during the last years, where invasive techniques are being used more often and in more emergent cardiac syndromes. Although conservative treatment combining aspirin and beta-blocker remains the recommended strategy in most cases, revascularization could also be suggested as a method of treatment in specific indications, but with a higher risk of complications. The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients. Follow-up should be performed on a regular basis.

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection

BACKGROUND

There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD).

METHODS

Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates.

RESULTS

A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range, IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval, CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support.

CONCLUSIONS

In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

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.

Psychosocial impacts of spontaneous coronary artery dissection: A qualitative study

Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute myocardial infarction, particularly in younger women without classic cardiac risk factors. While recent quantitative studies have noted high anxiety and depression in SCAD survivors, the full range and extent of psychosocial impacts of SCAD is unknown. The present study used a qualitative approach to investigate the psychosocial impacts of SCAD in Australian SCAD survivors. Focus group participants were recruited as part of a larger study of SCAD survivors currently being undertaken by the Victor Chang Cardiac Research Institute. Thirty SCAD survivors participated in one of seven online focus groups, conducted using a semi-structured format. Focus group duration was 1.5 hours. Each was digitally recorded and transcribed. Data were analyzed thematically according to recommended guidelines. One over-arching theme, five main themes and 26 sub-themes were identified. The over-arching theme related to lack of information, while the five main themes related to emotional impacts, issues with self-management, issues with family, impacts on work life, and the need for psychosocial support. The ‘emotional impacts’ theme comprised 11 sub-themes, namely shock and disbelief, confusion and uncertainty, unfairness, fear and anxiety, loss and grief, isolation and loneliness, guilt, invalidation and embarrassment, depression, vulnerability, and frustration. Findings are discussed in light of relevant psychological theories. This qualitative study extends previous quantitative investigations of SCAD survivors by providing an in-depth understanding of the complex, inter-related and highly distressing impacts of SCAD. The findings point to the urgent need for a coherent approach to information provision, the development and delivery of SCAD-specific cardiac rehabilitation programs, and the provision of psychosocial support programs for SCAD survivors.

Multiple Arterial Dissections and Connective Tissue Abnormalities

Background: Although patients with multiple arterial dissections in distinct arterial regions rarely present with known connective tissue syndromes, we hypothesized that mild connective tissue abnormalities are common findings in these patients. Methods: From a consecutive register of 322 patients with cervical artery dissection (CeAD), we identified and analyzed 4 patients with a history of additional dissections in other vascular beds. In three patients, dermal connective tissue was examined by electron microscopy. DNA from all four patients was studied by whole-exome sequencing and copy number variation (CNV) analysis. Results: The collagen fibers of dermal biopsies were pathologic in all three analyzed patients. One patient carried a CNV disrupting the COL3A1 and COL5A2 genes (vascular or hypermobility type of Ehlers–Danlos syndrome), and another patient a CNV in MYH11 (familial thoracic aortic aneurysms and dissections). The third patient carried a missense substitution in COL5A2. Conclusion: Three patients showed morphologic alterations of the dermal connective tissue, and two patients carried pathogenic variants in genes associated with arterial connective tissue dysfunction. The findings suggest that genetic testing should be recommended after recurrent arterial dissections, independently of apparent phenotypical signs of connective tissue disorders.

Case Report: Severe Peripartum Cardiac Disease in Myotonic Dystrophy Type 1

Background

Myotonic dystrophy type 1 (DM1) is a hereditary muscular dystrophy affecting ∼2.1–14.3/100,000 adults. Cardiac manifestations of DM1 include conduction disorders and rarely cardiomyopathies. DM1 increases the risk of obstetric complications, however, little is known about the relationship between pregnancy and cardiomyopathy in DM1 due to disease rarity.

Case

A 23-year-old with DM1 developed cardiomyopathy during pregnancy. Despite initial medical stabilization, she subsequently developed multiple spontaneous coronary artery dissections postpartum, worsening cardiomyopathy and multiorgan failure. She died 5 months postpartum.

Conclusion

Though cardiomyopathy and arterial dissection are both known complications of pregnancy, this case suggests individuals with myotonic dystrophy type 1 may be at heightened risk for cardiac disease during the peripartum period. Physicians caring for women with suspected or proven DM1 should offer counseling and be alerted to the risk of cardiac complications with pregnancy and in the peripartum period. Pregnant and peripartum women with DM1 are likely to benefit from more frequent assessments of cardiac function including echocardiograms and early institution of heart failure management protocols when symptoms of cardiomyopathy present.

Unusual Presentation of Post-coital Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a grave medical condition that is defined as a separation of the coronary artery wall layer. This presentation is rare in males and can be triggered by cardio-circulatory stress, such as exercise and emotional stress. Sexual intercourse is considered potent cardiovascular stress that can be strenuous and cause rapid and significant changes in the heart rate and blood pressure which can predispose SCAD. Herein, we are reporting a very rare case of a 41-year-old male gentleman who presented with SCAD after vigorous sexual intercourse. We are reporting this case to encourage physicians to educate their patients on the topic.

Antiplatelet therapy in patients with conservatively managed spontaneous coronary artery dissection from the multicentre DISCO registry

AIMS

The role of antiplatelet therapy in patients with spontaneous coronary artery dissection (SCAD) undergoing initial conservative management is still a matter of debate, with theoretical arguments in favour and against its use. The aims of this article are to assess the use of antiplatelet drugs in medically treated SCAD patients and to investigate the relationship between single (SAPT) and dual (DAPT) antiplatelet regimens and 1-year patient outcomes.

METHODS AND RESULTS

We investigated the 1-year outcome of patients with SCAD managed with initial conservative treatment included in the DIssezioni Spontanee COronariche (DISCO) multicentre international registry. Patients were divided into two groups according to SAPT or DAPT prescription. Primary endpoint was 12-month incidence of major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction (MI), and any unplanned percutaneous coronary intervention (PCI). Out of 314 patients included in the DISCO registry, we investigated 199 patients in whom SCAD was managed conservatively. Most patients were female (89%), presented with acute coronary syndrome (92%) and mean age was 52.3 ± 9.3 years. Sixty-seven (33.7%) were given SAPT whereas 132 (66.3%) with DAPT. Aspirin plus either clopidogrel or ticagrelor were prescribed in 62.9% and 36.4% of DAPT patients, respectively. Overall, a 14.6% MACE rate was observed at 12 months of follow-up. Patients treated with DAPT had a significantly higher MACE rate than those with SAPT [18.9% vs. 6.0% hazard ratios (HR) 2.62; 95% confidence intervals (CI) 1.22-5.61; P = 0.013], driven by an early excess of non-fatal MI or unplanned PCI. At multiple regression analysis, type 2a SCAD (OR: 3.69; 95% CI 1.41-9.61; P = 0.007) and DAPT regimen (OR: 4.54; 95% CI 1.31-14.28; P = 0.016) resulted independently associated with a higher risk of 12-month MACE.

CONCLUSIONS

In this European registry, most patients with SCAD undergoing initial conservative management received DAPT. Yet, at 1-year follow-up, DAPT, as compared with SAPT, was independently associated with a higher rate of adverse cardiovascular events (ClinicalTrial.gov id: NCT04415762).

Prevalence of Cervical Artery Abnormalities on CTA in Patients with Spontaneous Coronary Artery Dissection: Fibromuscular Dysplasia, Dissection, Aneurysm, and Tortuosity

BACKGROUND AND PURPOSE

Little is known about associations between spontaneous coronary artery dissection and cervical artery abnormalities. This study sought to assess the prevalence of cervical artery abnormalities among patients with spontaneous coronary artery dissection.

MATERIALS AND METHODS

A retrospective analysis was completed of patients who underwent CTA neck imaging as part of arterial assessment following the diagnosis of spontaneous coronary artery dissection. The internal carotid and vertebral arteries were evaluated for the presence of fibromuscular dysplasia, dissection and/or pseudoaneurysm, ectasia and/or aneurysmal dilation, atherosclerosis, and webs. Carotid tortuosity was categorized into kinks, loops, coils, and retrojugular and/or retropharyngeal carotid courses; vertebral tortuosity was classified by subjective analysis of severity.

RESULTS

Two hundred fourteen patients were included in the final cohort, of whom 205 (95.8%) were women; the average age was 54.4 years. Fibromuscular dysplasia was the most frequently observed abnormality (83 patients; 38.8%), followed by dissections and/or pseudoaneurysms (n = 28; 13.1%), ectasia and/or aneurysmal dilation (n = 22; 10.3%), and carotid webs (n = 10; 4.7%). At least 1 type of carotid tortuosity was present in 99 patients (46.3%). The majority (n = 185; 86.4%) of patients had no carotid atherosclerosis; and 26 (12.2%) had mild; 3 (1.4%), moderate; and 0, severe carotid atherosclerosis.

CONCLUSIONS

The most common abnormality in the cervical artery vasculature of patients with spontaneous coronary artery dissection is fibromuscular dysplasia. Cervical dissections were higher than previously reported but were not observed in most patients.

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.

Spontaneous coronary artery dissection with cardiogenic shock in the third trimester, and a successful early-term delivery: a case report

BACKGROUND

Acute myocardial infarction in pregnancy is occasionally due to spontaneous coronary artery dissection (SCAD). Although uncommon, the majority of cases of pregnancy-associated SCAD (pSCAD) has critical presentations with more profound defects that portend high maternal and foetal mortality, and frequently necessitate preterm delivery. This is a case of pSCAD with ongoing ischaemia that required temporary mechanical circulatory support (MCS) and emergent revascularization, while the pregnancy was successfully continued to early-term.

CASE SUMMARY

A 30-year-old woman G2P1 at Week 32 of gestation with no medical history, presented to the emergency department with severe chest pain. An electrocardiogram showed ST-segment elevation in the anterolateral leads. An emergent cardiac catheterization revealed dissection of the proximal left anterior descending (LAD) artery with TIMI (thrombolysis in myocardial infarction) 3 flow. Although initially stable, she later experienced recurrent chest pain and developed cardiogenic shock, necessitating MCS, and emergent revascularization. She was stabilized and remained closely monitored in the hospital prior to vaginal delivery at early-term.

DISCUSSION

This case of pSCAD at Week 32 of gestation complicated by refractory ischaemia illustrates the complexity of management, which requires a multi-disciplinary team to reduce both maternal and foetal mortality. Conservative management of SCAD, while preferred, is not always possible in the setting of ongoing ischaemia, particularly if complicated by cardiogenic shock. A thorough weighing of risks vs. benefits and ongoing discussions among multiple subspecialists in this case allowed for the stabilization of the patient and subsequent successful early-term delivery.

Spontaneous Coronary Artery Dissection: Case Series and Literature Review

Spontaneous coronary artery dissection (SCAD) is an important and rare cause of myocardial infarction (MI), particularly among young women without traditional atherosclerotic risk factors. Late pregnancy and postpartum period are associated with more risk for developing SCAD. No enough data exist regarding the ideal management of SCAD due to lack of randomized trials comparing medical therapy and revascularization strategies.

We present three cases of SCAD, two of them were postpartum women while one involved an obese young woman with no identifiable risk factors. We describe the pathophysiology, types of SCAD, risk factors, clinical presentation, and management approach. This case series highlights the need to raise awareness of SCAD and to facilitate accurate diagnosis promptly.

Surgery is an option in evolving myocardial infarction induced by spontaneous coronary artery dissection: a case report

Background

Spontaneous coronary artery dissection (SCAD) has emerged as one of the important yet rare causes of acute coronary syndrome that primarily affect young peripartum women without cardiovascular risk factors. Despite the recent improvements in diagnosis and recognition of the importance of SCAD, it remains poorly studied and there has been no consensus of opinion regarding its optimal management.

Case summary

A 29-year-old breastfeeding woman presented with 1-day history of severe chest pain radiating to the jaw and both shoulders. Cardiovascular examination, 12 leads electrocardiogram, and echocardiography were normal. Troponin levels were elevated; hence, coronary angiogram was done and showed type 2 SCAD of the left anterior descending artery (LAD). The patient was managed conservatively. The next day, she started again to complain of severe chest pain and her troponin levels continued to rise. Repeated coronary angiogram revealed progression of the previous LAD dissection. Another dissection was also noticed in the left circumflex artery. Chest pain recurred over the night and her troponin levels continued to rise. An emergency coronary artery bypass grafting (CABG) was performed. The patient was doing well postoperatively and was discharged home on Day 8.

Discussion

Our patient presented with acute ischaemic changes secondary to SCAD. The report illustrates the risk factors, pathogenesis, diagnostic work up, and the possible therapeutic options of SCAD, which include conservative management and CABG. The management varies depending on the clinical presentation and the extent of the coronary artery dissection.

Spontaneous Coronary Artery Dissection and Fibromuscular Dysplasia: Vasculopathies With a Predilection for Women

The burden of cardiovascular disease in women is being increasingly appreciated. Nevertheless, both clinicians and the general public are largely unaware that cardiovascular disease is the leading cause of death worldwide in women in all countries and that outcomes after a heart attack are worse for women than men. Of note, certain types of cardiovascular disease have a predilection for women, including spontaneous coronary artery dissection (SCAD) and fibromuscular dysplasia (FMD). Although uncommon, SCAD is being increasingly recognised as the cause of an acute coronary syndrome (ACS) and can recur. It is a potentially fatal, under-diagnosed condition that affects relatively young women, who often have few traditional risk factors, and is the commonest cause of a myocardial infarction associated with pregnancy. In contrast, FMD often remains silent but when manifested can also cause major sequelae, including renal infarction, stroke, cervical artery dissection and gut infarction. Here we provide an update on the diagnosis, aetiology and management of these important disorders that overwhelmingly affect women.

Spontaneous Coronary Artery Dissection in a Young Man

Spontaneous coronary artery dissection (SCAD) is an idiosyncratic phenomenon by which a spontaneous separation of the intimal and medial layer in the coronary artery occurs with intramural hemorrhage in the absence of trauma. This intramural hematoma, in turn, leads to compression and occlusion of the arterial lumen. Unlike traumatic dissection of coronary arteries, more than half of SCAD heals spontaneously over time. SCAD is known to occur predominantly in women under the age of 50, particularly during pregnancy or peripartum period. Herein, we present a case of a 32-year-old man with an SCAD on the left anterior descending coronary artery. The discordance between clinical presentation and angiographic finding posed a unique challenge in therapeutic decision making. This case reminds clinicians that SCAD should be kept in mind as a differential diagnosis even for young men presenting with acute chest pain.