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Milani M, Bertaina M, Ardissino M, Iannaccone M, Boccuzzi GG, Tavecchia G, Oliva F, Sacco A. Unveiling an insidious diagnosis and its implications for clinical practice: Individual patient data systematic review of pregnancy-associated spontaneous coronary artery dissection. Int J Cardiol 2024; 418:132582. [PMID: 39313118 DOI: 10.1016/j.ijcard.2024.132582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Revised: 09/10/2024] [Accepted: 09/18/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND Pregnancy-Associated Spontaneous Coronary Artery Dissection (P-SCAD) is the most common cause of myocardial infarction in pregnancy and postpartum. Aim of this systematic review is to provide a descriptive picture of P-SCAD presentation, clinical course, management and outcomes. METHODS International databases were systematically screened up to November 2023 and all published P-SCAD case reports/series identified; additionally, we gathered four original cases, establishing a new database for the derived cohort. RESULTS 253 studies (215 case reports, 38 case series) were included for the analysis, enrolling 316 patients admitted between 1952 and 2023. Median age was 34 (SD 5) years old, 64 (20.4 %) were prepartum, 249 (79.6 %) postpartum. Most common presentation was ST-elevation myocardial infarction (72.6 %). Cardiac arrest and cardiogenic shock occurred in 18.4 % and 16.1 %, respectively. Multivessel dissection was present in 45.2 % of cases, with left anterior descending artery being most frequently affected (74.4 %). Initial therapeutic strategy was medical therapy in 54.8 % while upfront revascularization was performed in 45.2 % of cases. Excluding autoptic studies, mortality rate was 4.1 %, without significant differences between pre and postpartum SCAD (p-value 0.6) or according to initial therapeutic approach (p-value 0.5). Recurrences after index event were registered in 74 patients (23.4 %), being more common after medical treatment than in case of immediate revascularization (30.8 versus 18.3 %, p-value 0.02). CONCLUSIONS P-SCAD is a complex clinical scenario: timely diagnosis is difficult, therapeutic management not well-defined, rate of recurrences not negligible. Additional observational studies and dedicated registries are necessary to enhance the management of this rare but severe condition.
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Affiliation(s)
- Martina Milani
- Cardiology Department, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Maurizio Bertaina
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Torino, Italy.
| | - Maddalena Ardissino
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Torino, Italy
| | | | - Giovanni Tavecchia
- Cardiac Intensive Care Unit, "De Gasperis Cardio Center", ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- Cardiac Intensive Care Unit, "De Gasperis Cardio Center", ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alice Sacco
- Cardiac Intensive Care Unit, "De Gasperis Cardio Center", ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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2
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Bihag Z, Patail H, Ghani A, McKay RG, Haider J, Rizvi A, Fram DB. Spontaneous coronary artery dissection: a case series illustrating current challenges in diagnosis and treatment. Future Cardiol 2024; 20:369-376. [PMID: 39115442 PMCID: PMC11457618 DOI: 10.1080/14796678.2024.2355808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/13/2024] [Indexed: 10/02/2024] Open
Abstract
Spontaneous coronary artery dissection (SCAD) has been increasingly recognized in recent years as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, especially among young women. However, due to the lack of clinical trials on SCAD, evidence-based guidance on management is currently lacking. Presented are four case studies that illustrate the recent insights and challenges in SCAD diagnosis and treatment.
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Affiliation(s)
- Zade Bihag
- University of Connecticut, UConn Health, Department of Internal Medicine, Farmington, Connecticut, USA
| | - Haris Patail
- University of Connecticut, UConn Health, Department of Internal Medicine, Farmington, Connecticut, USA
| | - Ali Ghani
- Hartford Hospital, Department of Interventional Cardiology, Hartford, Connecticut, USA
| | - Raymond G McKay
- Hartford Hospital, Department of Interventional Cardiology, Hartford, Connecticut, USA
| | - Jawad Haider
- Hartford Hospital, Department of Interventional Cardiology, Hartford, Connecticut, USA
| | - Asad Rizvi
- Hartford Hospital, Department of Interventional Cardiology, Hartford, Connecticut, USA
| | - Daniel Bruce Fram
- Hartford Hospital, Department of Interventional Cardiology, Hartford, Connecticut, USA
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3
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Cosma J, Russo A, Ferradini V, Gobbi C, Mallia V, Zuffi A, Joret C, Sacca S, Mango R. Spontaneous coronary artery dissection: review, case report and analysis of COVID-19-related cases. Minerva Cardiol Angiol 2024; 72:251-265. [PMID: 36847436 DOI: 10.23736/s2724-5683.22.06195-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) accounts for 1-4% of all acute coronary syndromes (ACS). Since the first description in 1931, our understanding of the disease has evolved; however, its pathophysiology and management are still a matter of debate. SCAD typically occurs in a middle-aged woman with no or few traditional cardiovascular risk factors. Two hypotheses have been proposed to explain the pathophysiology depending on the primary event: an intimal tear in the "inside-out" hypothesis and a spontaneous hemorrhage from the vasa vasorum in the "outside-in" hypothesis. Etiology appears to be multifactorial: different predisposing and precipitating factors have been identified. Coronary angiography is the gold standard for the diagnosis of SCAD. Current recommendations on the treatment of SCAD patients are based on expert opinions: a conservative strategy is preferred in hemodynamically stable SCAD patients, while urgent revascularization should be considered in hemodynamically unstable patients. Eleven cases of SCAD in COVID-19 patients have already been described: although the exact pathophysiological mechanism remains unclear, COVID-19-related SCAD is considered a combination of significant systemic inflammatory response and localized vascular inflammation. We present a literature review of SCAD, and we report an unpublished case of SCAD in a COVID-19 patient.
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Affiliation(s)
- Joseph Cosma
- Cardiovascular Institute of Caen, Saint Martin Private Hospital, Caen, France -
| | - Alessandro Russo
- Department of Cardiology, Ospedale Civile di Mirano, Mirano, Venice, Italy
| | - Valentina Ferradini
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Cecilia Gobbi
- Cardiovascular Institute of Caen, Saint Martin Private Hospital, Caen, France
| | - Vincenzo Mallia
- Cardiovascular Institute of Caen, Saint Martin Private Hospital, Caen, France
| | - Andrea Zuffi
- Cardiovascular Institute of Caen, Saint Martin Private Hospital, Caen, France
| | - Cédric Joret
- Cardiovascular Institute of Caen, Saint Martin Private Hospital, Caen, France
| | - Salvatore Sacca
- Department of Cardiology, Ospedale Civile di Mirano, Mirano, Venice, Italy
| | - Ruggiero Mango
- Department of Cardiovascular Disease, Tor Vergata University, Rome, Italy
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4
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Kim CW, Frishman WH, Aronow WS. Spontaneous Coronary Artery Dissection: Review of Possible Pathophysiological Risk Factors. Cardiol Rev 2023; 31:207-214. [PMID: 36288472 DOI: 10.1097/crd.0000000000000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that typically affects the younger and healthier female population without the typical ACS risk factors such as hypertension, diabetes, or hyperlipidemia. The clinical presentation of SCAD can be diverse and the diagnosis is typically by coronary angiography but also can require advanced imaging such as intravascular ultrasound or optical coherence tomography. Past studies have shown the atypical patient characteristics of SCAD patients among ACS patients. The main challenge is that the exact pathophysiology of SCAD is unknown. Potential pathophysiological risk factors are discussed including fibromuscular dysplasia, other arteriopathies, pregnancy and female sex hormone changes, migraines, inflammatory conditions, and stress. The current understanding of these risk factors along with potential pathophysiological mechanisms are discussed. There still remain many areas of additional investigation in understanding this rare cause of ACS.
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Affiliation(s)
- Chan W Kim
- From the Cardiology Division, and the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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5
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Wahinya M, Ngunjiri MM, Khan Z. Spontaneous Coronary Arterial Dissection in a Young Female in the Postpartum Period: A Case Report From Sub-Saharan Africa. Cureus 2023; 15:e39507. [PMID: 37378180 PMCID: PMC10291357 DOI: 10.7759/cureus.39507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
Spontaneous coronary arterial dissection (SCAD) has become an important cause of acute coronary syndrome (ACS) and sudden cardiac death, particularly in young women, without classic atherosclerotic cardiovascular risk factors. Missed diagnosis is common due to a low index of suspicion in these patients. Here, we present a case of a 29-year-old African female in the postpartum period who presented with a two-week history of heart failure symptoms and acute onset chest pain. An electrocardiogram showed ST-segment elevation myocardial infarction (STEMI) with elevated high-sensitivity troponin T. Echocardiography on admission revealed an ejection fraction of 40% with septal hypokinesia. Coronary angiography showed multivessel dissection with type 1 SCAD in the left circumflex artery and type 2 SCAD in the left anterior descending artery. The patient was managed conservatively, and angiographic healing of SCAD together with normalization of the left ventricular systolic dysfunction was seen after four months. SCAD should always be in the differential diagnosis of any peripartum patient who presents with ACS and lacks the typical atherosclerotic risk factors. Accurate diagnosis and appropriate management are paramount in such cases.
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Affiliation(s)
- Maureen Wahinya
- Internal Medicine, Kenyatta University Teaching, Referral and Research Hospital, Nairobi, KEN
| | - Morgan M Ngunjiri
- Internal Medicine, Kenyatta University Teaching, Referral and Research Hospital, Nairobi, KEN
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
- Cardiology, Barts Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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6
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Tapaskar N, Tremblay-Gravel M, Khush KK. Contemporary Management of Cardiogenic Shock During Pregnancy. J Card Fail 2023; 29:193-209. [PMID: 36243342 DOI: 10.1016/j.cardfail.2022.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
Cardiogenic shock is the most extreme cardiovascular disease state during pregnancy. Peripartum cardiomyopathy is the most common cause of cardiogenic shock toward the end of pregnancy and in the early postpartum period. Therapy for cardiogenic shock relies on appropriate phenotyping of shock etiology, severity and ventricular predominance, which are critical in the appropriate selection of medical and mechanical therapy. Mechanical circulatory support may be used as a bridge to recovery or as definitive therapy. Intra-aortic balloon pumps, percutaneous left ventricular assist devices and venoarterial extracorporeal circulatory devices have been successfully used in pregnancy and the postpartum period. The most commonly used mechanical therapy in the pregnant patient is extracorporeal membranous oxygenation circulatory support. The use of mechanical circulatory devices in peripartum cardiomyopathy has contributed to improved survival rates in recent years. Further efforts to identify the optimal mechanical circulatory support strategy for peripartum cardiomyopathy and cardiogenic shock in the peripartum period are needed.
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Affiliation(s)
- Natalie Tapaskar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | | | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
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7
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Cano-Castellote M, Afanador-Restrepo DF, González-Santamaría J, Rodríguez-López C, Castellote-Caballero Y, Hita-Contreras F, Carcelén-Fraile MDC, Aibar-Almazán A. Pathophysiology, Diagnosis and Treatment of Spontaneous Coronary Artery Dissection in Peripartum Women. J Clin Med 2022; 11:jcm11226657. [PMID: 36431134 PMCID: PMC9692787 DOI: 10.3390/jcm11226657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is an infrequent cause of nonobstructive ischemic heart disease in previously healthy young women and therefore is not usually considered in differential diagnoses. The overall incidence of SCAD in angiographic series is between 0.28 and 1.1%, with a clear predominance in young, healthy women (70%) of whom approximately 30% are in the postpartum period. In the United Kingdom, between 2008 and 2012, SCAD was the cause of 27% of acute myocardial infarctions during pregnancy, with a prevalence of 1.81 per 100,000 pregnancies. Regarding the mechanism of arterial obstruction, this may be due to the appearance of an intramural hematoma or to a tear in the intima of the arteries, both spontaneously. Although multiple diagnostic methods are available, it is suggested to include an appropriate anamnesis, an electrocardiogram in the first 10 min after admission to the service or the onset of symptoms, and subsequently, a CT angiography of the coronary arteries or urgent coronary angiography if the hemodynamic status of the patient allows it. Treatment should be individualized for each case; however, the appropriate approach is generally based on two fundamental pillars: conservative medical treatment with antiplatelet agents, beta-blockers, and nitrates, and invasive treatment with percutaneous coronary intervention for stent implantation or balloon angioplasty, if necessary.
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Affiliation(s)
- Marta Cano-Castellote
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain
| | - Diego Fernando Afanador-Restrepo
- Faculty of Distance and Virtual Education, Antonio José Camacho University Institution, Santiago de Cali 760016, Colombia
- ZIPATEFI Research Group, Faculty of Health Sciences and Sports, University Foundation of the Área Andina, Pereira 660001, Colombia
| | - Jhonatan González-Santamaría
- ZIPATEFI Research Group, Faculty of Health Sciences and Sports, University Foundation of the Área Andina, Pereira 660001, Colombia
- Faculty of Health Sciences, Technological University of Pereira, Pereira 660001, Colombia
- Nutrition Sciences Postgraduate, Faculty of Nutrition Sciences, University of Sinaloa, Culiacan 80019, Mexico
| | | | | | - Fidel Hita-Contreras
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain
| | | | - Agustín Aibar-Almazán
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain
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8
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Herling de Oliveira LL, Correia VM, Nicz PFG, Soares PR, Scudeler TL. MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment. J Clin Med 2022; 11:jcm11195497. [PMID: 36233366 PMCID: PMC9571924 DOI: 10.3390/jcm11195497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.
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9
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Park K, Bortnick AE, Lindley KJ, Sintek M, Sethi S, Choi C, Davis MB, Walsh MN, Voeltz M, Bello NA, Saw J, Ahmed MM, Smilowitz NR, Vidovich MI. Interventional Cardiac Procedures and Pregnancy. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100427. [PMID: 39131483 PMCID: PMC11307807 DOI: 10.1016/j.jscai.2022.100427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 08/13/2024]
Abstract
As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.
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Affiliation(s)
- Ki Park
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Anna E. Bortnick
- Department of Medicine, Division of Cardiology, Maternal and Fetal Medicine-Cardiology Joint Program and Department of Medicine, Division of Geriatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Kathryn J. Lindley
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Marc Sintek
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Sanjum Sethi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Calvin Choi
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Melinda B. Davis
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
| | | | - Michele Voeltz
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | - Natalie A. Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Mustafa M. Ahmed
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Nathaniel R. Smilowitz
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | - Mladen I. Vidovich
- Department of Medicine, Division of Cardiology, University of Illinois, Chicago, Illinois
| | - American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
- Department of Medicine, Division of Cardiology, Maternal and Fetal Medicine-Cardiology Joint Program and Department of Medicine, Division of Geriatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
- St. Vincent Heart Center, Indianapolis, Indiana
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
- Department of Medicine, Division of Cardiology, University of Illinois, Chicago, Illinois
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10
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Mantovani F, Navazio A, Tortorella G, Guiducci V. Unique Case of Spontaneous Left Main Coronary Dissection in Second Trimester of Pregnancy Successfully Treated with Percutaneous Coronary Intervention: A Happy Ending. J Cardiovasc Dev Dis 2021; 9:jcdd9010009. [PMID: 35050219 PMCID: PMC8779120 DOI: 10.3390/jcdd9010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 11/27/2022] Open
Abstract
Among pregnant women, SCAD is the most frequent etiology of non-atherosclerotic acute coronary syndrome. SCAD related to pregnancy is more frequent within the first month (especially first week) of puerperium or last trimester, or is otherwise anecdotal. The concomitance of SCAD and pregnancy poses many issues regarding diagnosis and treatment in respect to maternal and fetal safety and requires tailored intervention with close interaction between clinical cardiologists, interventional cardiologists, cardiothoracic surgeons, and obstetricians. We report the case of a patient, pregnant in the second trimester with a life-threatening SCAD, successfully treated with percutaneous coronary intervention with excellent outcome for mother and baby.
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Affiliation(s)
- Francesca Mantovani
- Cardiology, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (A.N.); (V.G.)
- Correspondence:
| | - Alessandro Navazio
- Cardiology, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (A.N.); (V.G.)
| | - Giovanni Tortorella
- Azienda AUSL Parma-Presidio Ospedaliero Di Fidenza Vaio, Via Don Enrico Tincati 5, 43036 Parma, Italy;
| | - Vincenzo Guiducci
- Cardiology, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (A.N.); (V.G.)
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11
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Adams C, He M, Hughes I, Singh K. Mortality in spontaneous coronary artery dissection: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2021; 98:1211-1220. [PMID: 33491851 DOI: 10.1002/ccd.29488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/30/2020] [Accepted: 12/13/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to provide a comprehensive estimate for spontaneous coronary artery dissection (SCAD) related mortality, and explore factors associated with an increased risk of death. BACKGROUND SCAD is an infrequent but increasingly recognized cause of acute coronary syndrome. Despite a growing body of evidence, there have been few detailed examinations of SCAD associated mortality. METHODS We searched MEDLINE, EMBASE, Cochrane, Web of Science and Google Scholar databases through May 7, 2020. We included studies reporting mortality data, confirmed SCAD with coronary angiography and included ≥10 participants. We excluded non-English studies, conference abstracts, review articles and duplicate datasets. Random-effects meta-analysis and meta-regression were used to evaluate estimates and predictors of mortality. RESULTS From an initial 1,131 articles, 34 studies with 2,817 patients were eligible for inclusion. The weighted mean age was 50 years, and 84% of participants were female. The pooled estimate for SCAD mortality was 1% (Proportion 0.01; 95% CI, 0.00-0.02). The mean duration of follow-up was 33 months. Meta-regression showed male sex was associated with 3.5-fold increased odds of mortality (OR, 3.50; 95% CI, 1.22-10.03). In addition, smoking (current or previous) was associated with a 15-fold increased risk of mortality (OR 15.32; 95% CI, 2.88-81.41). CONCLUSIONS This meta-analysis has shown that SCAD is associated with favorable survival outcomes with an estimated mortality of 1% over a mean follow-up period of 33 months. We also found male sex and smoking were associated with an increased risk of mortality.
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Affiliation(s)
- Cobi Adams
- Department of Medicine, Bond University, Robina, Queensland, Australia.,Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Maggie He
- Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Department of Medicine, Griffith University, Southport, Queensland, Australia
| | - Ian Hughes
- Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Kuljit Singh
- Department of Medicine, Bond University, Robina, Queensland, Australia.,Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Department of Medicine, Griffith University, Southport, Queensland, Australia
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12
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Bocchino PP, Franchin L, Angelini F, D'Ascenzo F, De Ferrari GM, Alfonso F. Outcomes during the first year following spontaneous coronary artery dissection: A systematic timeframe pooled analysis. Catheter Cardiovasc Interv 2021; 99:472-479. [PMID: 34773431 DOI: 10.1002/ccd.30016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/11/2021] [Accepted: 10/27/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We aimed to compare the incidence and timing of major adverse cardiovascular events (MACE) within the first year after spontaneous coronary artery dissection (SCAD) according to the management strategy: conservative versus invasive. BACKGROUND Treatment of SCAD remains controversial. METHODS A pooled analysis of studies providing separate individual clinical outcomes for conservative and invasive treatment strategies within 1 year after SCAD was performed. The primary outcome measure was MACE incidence within three predefined study periods after SCAD, namely "in-hospital", "discharge-to-6-months" and "6-to-12-months". MACE was defined as a composite of all-cause death, myocardial infarction, target vessel revascularization, heart failure and SCAD recurrence. RESULTS A total of 16 studies (444 patients) were included; 277 (62%) patients were treated conservatively and 167 (38%) invasively. Within 1-year follow-up, 39 (67%) MACE occurred during the in-hospital period compared to 10 (17%) in the "discharge-to-6 months" period and 9 (16%) in the "6-to-12-months" period (p < 0.0001 for the overall comparison). MACE incidence was also significantly different between the three study periods in the conservatively-treated group (23 [78%] vs. 7 [23%] vs. 0 [0%], respectively; p < 0.0001) and the invasively-treated group (12 [66%] vs. 3 [17%] vs. 3 [17%], respectively; p < 0.0001), although no significant difference was found regarding MACE incidence in the intra-period comparisons between conservative and invasive treatment strategies. CONCLUSIONS This pooled analysis showed that most MACE following SCAD occurred during the in-hospital period compared to the following two semesters, regardless of the treatment strategy. No difference regarding MACE incidence was found between conservative and invasive strategies in each study period.
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Affiliation(s)
- Pier Paolo Bocchino
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Luca Franchin
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBER-CV, Madrid, Spain
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13
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Samuel R, Alfadhel M, McAlister C, Nestelberger T, Saw J. Coronary Events in the Pregnant Patient: Who Is at Risk and How Best to Manage? Can J Cardiol 2021; 37:2026-2034. [PMID: 34530109 DOI: 10.1016/j.cjca.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022] Open
Abstract
Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimise maternal and fetal outcomes. The early involvement of the "cardio-obstetrics" team in prepregnancy counselling, the antenatal period, delivery, and postpartum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing owing to a number of factors, including advancing maternal age and increases in traditional cardiac risk factors contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have previous coronary disease, and the pathologic mechanisms involved are predominantly nonatherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnoses, and management strategies for patients at risk of or presenting with coronary events in pregnancy.
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Affiliation(s)
- Rohit Samuel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
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Merlo AC, Rosa GM, Porto I. Pregnancy-related acute myocardial infarction: a review of the recent literature. Clin Res Cardiol 2021; 111:723-731. [PMID: 34510263 PMCID: PMC9242969 DOI: 10.1007/s00392-021-01937-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 12/18/2022]
Abstract
Pregnancy-related acute myocardial infarction is a rare and potentially life-threatening cardiovascular event, the incidence of which is growing due to the heightened prevalence of several risk factors, including increased maternal age. Its main aetiology is spontaneous coronary artery dissection, which particularly occurs in pregnancy and may engender severe clinical scenarios. Therefore, despite frequently atypical and deceptive presentations, early recognition of such a dangerous complication of gestation is paramount. Notwithstanding diagnostic and therapeutic improvements, pregnancy-related acute myocardial infarction often carries unfavourable outcomes, as emergent management is difficult owing to significant limitations in the use of ionising radiation-e.g. during coronary angiography, potentially harmful to the foetus even at low doses. Notably, however, maternal mortality has steadily decreased in recent decades, indicating enhanced awareness and major medical advances in this field. In our paper, we review the recent literature on pregnancy-related acute myocardial infarction and highlight the key points in its management.
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Affiliation(s)
- Andrea Carlo Merlo
- Department of Internal Medicine and Medical Specialties (DIMI), Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialties (DIMI), Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy
- Cardiology Unit, DICATOV-Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI), Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy.
- Cardiology Unit, DICATOV-Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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15
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Krittanawong C, Gulati R, Eitzman D, Jneid H. Revascularization in Patients With Spontaneous Coronary Artery Dissection: Where Are We Now? J Am Heart Assoc 2021; 10:e018551. [PMID: 34187166 PMCID: PMC8403332 DOI: 10.1161/jaha.120.018551] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/23/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Chayakrit Krittanawong
- Section of CardiologyBaylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical CenterHoustonTX
| | - Rajiv Gulati
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | - Daniel Eitzman
- Department of Internal MedicineCardiovascular Research CenterUniversity of MichiganAnn ArborMI
| | - Hani Jneid
- Section of CardiologyBaylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical CenterHoustonTX
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Prudhvi K, Jonnadula J, Rokkam VRP, Kutti Sridharan G. Pregnancy associated spontaneous coronary artery dissection: A case report and review of literature. World J Cardiol 2021; 13:103-110. [PMID: 33968309 PMCID: PMC8069519 DOI: 10.4330/wjc.v13.i4.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/01/2021] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pregnancy-associated spontaneous coronary artery dissection (PSCAD) is an important cause of chest pain and acute myocardial infarction in pregnant and postpartum women. Pregnancy is considered an isolated risk factor for spontaneous coronary artery dissection. The etiology, pathogenesis, and incidence of PSCAD are not known.
CASE SUMMARY We present a case of a 33-year-old postpartum female who presented with sudden onset chest pain and was diagnosed with spontaneous coronary artery dissection and needed urgent catheterization revealing left anterior descending coronary artery dissection. She underwent emergent coronary artery bypass graft surgery with good post-operative recovery.
CONCLUSION Most patients with PSCAD can be managed conservatively with medical management and have good outcomes. Patients with high-risk presentations benefit from the invasive approach. Coronary artery bypass graft may be required in select few patients based on angiography findings. Due to the risk of recurrent spontaneous coronary artery dissection, subsequent pregnancies are discouraged.
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Affiliation(s)
- Kalyan Prudhvi
- Division of Critical Care Medicine, Mercy Hospital, Saint Louis University School of Medicine, St. Louis, MO 63141, United States
| | - Jayasree Jonnadula
- Department of Geriatric Medicine, Barnes Jewish Hospital/Washington University, St. Louis, MO 63110, United States
| | - Venkata Ram Pradeep Rokkam
- Division of Inpatient Medicine, University of Arizona/Banner University Medical Center, Tucson, AZ 85719, United States
| | - Gurusaravanan Kutti Sridharan
- Division of Inpatient Medicine, University of Arizona/Banner University Medical Center, Tucson, AZ 85719, United States
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18
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Bocchino PP, Angelini F, Franchin L, D'Ascenzo F, Fortuni F, De Filippo O, Conrotto F, Alfonso F, Saw J, Escaned J, Liu C, De Ferrari GM. Invasive versus conservative management in spontaneous coronary artery dissection: A meta-analysis and meta-regression study. Hellenic J Cardiol 2021; 62:297-303. [PMID: 33689856 DOI: 10.1016/j.hjc.2021.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/02/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Data regarding the best treatment for spontaneous coronary artery dissection (SCAD) are limited. The aim of the present study was to compare the clinical outcomes of conservative versus invasive treatment in SCAD patients. METHODS We systematically searched the literature for studies evaluating the comparative efficacy and safety of invasive revascularization versus medical therapy for the treatment of SCAD from 1990 to 2020. The study endpoints were all-cause death, cardiovascular death, myocardial infarction, heart failure, SCAD recurrence and target vessel revascularization (TVR) rates. Random effect meta-analysis was performed by comparing the clinical outcomes between the two groups. A univariate meta-regression analysis was also performed. RESULTS Twenty-four observational studies with 1720 patients were included. After 28 ± 14 months, a conservative approach was associated with lower TVR rate compared with invasive treatment (OR = 0.50; 95%CI 0.28-0.90; P = 0.02). No statistical difference was found regarding all-cause death (OR = 0.81; 95%CI 0.31-2.08; P = 0.66), cardiovascular death (OR = 0.89; 95%CI 0.15-5.40; P = 0.89), myocardial infarction (OR = 0.95; 95%CI 0.50-1.81; P = 0.87), heart failure (OR 0.96; 95%CI 0.41-2.22; P = 0.92) and SCAD recurrence (OR = 0.94; 95%CI 0.52-1.72; P = 0.85). The meta-regression analysis suggested that male gender, diabetes mellitus, smoking habit, prior coronary artery disease, left main coronary artery involvement, lower ejection fraction and low TIMI flow at admission were related with high overall mortality, whereas SCAD recurrence was higher among patients with fibromuscular dysplasia. CONCLUSIONS A conservative approach was associated with similar clinical outcomes and lower TVR rates compared with an invasive strategy in SCAD patients; future prospective studies are needed to confirm these results.
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Affiliation(s)
- Pier Paolo Bocchino
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy.
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Luca Franchin
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Federico Fortuni
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBER-CV, Madrid, Spain
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Javier Escaned
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, Madrid, Spain
| | - Chengwei Liu
- Department of Cardiology, Wuhan Asia Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
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19
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Kermali M, Zahra SA, Hewage S, Al Nahian S, Harky A. Spontaneous coronary artery dissection: presentation and management options. Coron Artery Dis 2021; 32:152-163. [PMID: 32694362 DOI: 10.1097/mca.0000000000000926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Coronary artery dissection is a serious, life-threatening heart condition. It can occur spontaneously or due to traumatic or iatrogenic causes. Spontaneous coronary artery dissection (SCAD) is often misdiagnosed as most patients present with symptoms resembling those of an acute coronary syndrome. Clinical sequelae of SCAD include debilitating morbidities such as myocardial infarction, myocardial ischaemia, sudden cardiac death, ventricular arrhythmias amongst many other myocardial ischaemia associated complications. There are two main methods of managing patients with SCAD; conservative management with medical therapy or revascularisation by percutaneous coronary intervention or coronary artery bypass grafting.
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Affiliation(s)
| | | | - Savini Hewage
- Faculty of Medicine, St George's, University of London, London
| | - Syed Al Nahian
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital
- Faculty of Life Sciences, University of Liverpool, Liverpool, UK
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20
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Avila WS, Alexandre ERG, Castro MLD, Lucena AJGD, Marques-Santos C, Freire CMV, Rossi EG, Campanharo FF, Rivera IR, Costa MENC, Rivera MAM, Carvalho RCMD, Abzaid A, Moron AF, Ramos AIDO, Albuquerque CJDM, Feio CMA, Born D, Silva FBD, Nani FS, Tarasoutchi F, Costa Junior JDR, Melo Filho JXD, Katz L, Almeida MCC, Grinberg M, Amorim MMRD, Melo NRD, Medeiros OOD, Pomerantzeff PMA, Braga SLN, Cristino SC, Martinez TLDR, Leal TDCAT. Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease - 2020. Arq Bras Cardiol 2020; 114:849-942. [PMID: 32491078 PMCID: PMC8386991 DOI: 10.36660/abc.20200406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Marildes Luiza de Castro
- Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas gerais (UFMG),Belo Horizonte, MG - Brasil
| | | | - Celi Marques-Santos
- Universidade Tiradentes,Aracaju, SE - Brasil
- Hospital São Lucas, Rede D'Or Aracaju,Aracaju, SE - Brasil
| | | | - Eduardo Giusti Rossi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Felipe Favorette Campanharo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein,São Paulo, SP - Brasil
| | | | - Maria Elizabeth Navegantes Caetano Costa
- Cardio Diagnóstico,Belém, PA - Brasil
- Centro Universitário Metropolitano da Amazônia (UNIFAMAZ),Belém, PA - Brasil
- Centro Universitário do Estado Pará (CESUPA),Belém, PA - Brasil
| | | | | | - Alexandre Abzaid
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Carlos Japhet da Mata Albuquerque
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
- Hospital Barão de Lucena, Recife, PE – Brazil
- Hospital EMCOR, Recife, PE – Brazil
- Diagnósticos do Coração LTDA, Recife, PE – Brazil
| | | | - Daniel Born
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Fernando Souza Nani
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - José de Ribamar Costa Junior
- Hospital do Coração (HCor),São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
| | | | - Max Grinberg
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Nilson Roberto de Melo
- Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
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21
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Alasnag M, Truesdell AG, Williams H, Martinez SC, Qadri SK, Skendelas JP, Jakobleff WA, Alasnag M. Mechanical Circulatory Support: a Comprehensive Review With a Focus on Women. Curr Atheroscler Rep 2020; 22:11. [DOI: 10.1007/s11883-020-0828-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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22
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Gad MM, Mahmoud AN, Saad AM, Bazarbashi N, Ahuja KR, Karrthik AK, Elgendy IY, Elgendy AY, Don CW, Hira RS, Massoomi MR, Saw J, Anderson RD, Kapadia SR. Incidence, Clinical Presentation, and Causes of 30-Day Readmission Following Hospitalization With Spontaneous Coronary Artery Dissection. JACC Cardiovasc Interv 2020; 13:921-932. [PMID: 32327089 DOI: 10.1016/j.jcin.2019.12.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/29/2019] [Accepted: 12/19/2019] [Indexed: 10/24/2022]
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23
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Jamil A, Tajrishi FZ, Kahe F, Najafi H, Montazerin SM, Shojaei F, Chitsazan M, Chitsazan M, Liu Y, Chi G. Spontaneous coronary artery dissection managed with a conservative or revascularization approach. J Cardiovasc Med (Hagerstown) 2020; 21:42-50. [DOI: 10.2459/jcm.0000000000000891] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Seecheran RV, Kawall J, Ramadhin D, Seecheran VK, Persad SA, Lalla SS, Seecheran NA. Preeclampsia-Associated Multivessel Spontaneous Coronary Artery Dissection. J Investig Med High Impact Case Rep 2019; 7:2324709619874624. [PMID: 31509019 PMCID: PMC6740047 DOI: 10.1177/2324709619874624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pregnancy-associated spontaneous coronary artery dissection (PASCAD) accounts for less than 5% of spontaneous coronary artery dissection cases and is comparatively more fulminant or clinically aggressive. Several factors associated with PASCAD include black ethnicity, multiparity, hypertension, advanced maternal age, and age at first childbirth. This atypical case highlights a preeclamptic patient presenting with an ST-segment elevation myocardial infarction in which multivessel dissection of both the left anterior descending and right coronary arteries were deemed co-culprit lesions for the index event.
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Affiliation(s)
| | - Jessica Kawall
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Divya Ramadhin
- Advanced Cardiovascular Institute, Port of Spain, Trinidad and Tobago
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26
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Spontaneous coronary artery dissections and fibromuscular dysplasia: Current insights on pathophysiology, sex and gender. Int J Cardiol 2019; 286:220-225. [DOI: 10.1016/j.ijcard.2018.11.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 12/14/2022]
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27
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Spontaneous coronary artery dissection and its association with takotsubo syndrome: Novel insights from a tertiary center registry. Catheter Cardiovasc Interv 2019; 95:485-491. [DOI: 10.1002/ccd.28314] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/22/2019] [Accepted: 04/15/2019] [Indexed: 12/24/2022]
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28
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Gilhofer TS, Saw J. Spontaneous coronary artery dissection: a review of complications and management strategies. Expert Rev Cardiovasc Ther 2019; 17:275-291. [DOI: 10.1080/14779072.2019.1598261] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Thomas S. Gilhofer
- Division of Cardiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, BC, Canada
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29
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Saw J. Pregnancy-Associated Spontaneous Coronary Artery Dissection Represents an Exceptionally High-Risk Spontaneous Coronary Artery Dissection Cohort. Circ Cardiovasc Interv 2019; 10:CIRCINTERVENTIONS.117.005119. [PMID: 28302643 DOI: 10.1161/circinterventions.117.005119] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jacqueline Saw
- From the Division of Cardiology, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
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30
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Macaya F, Salinas P, Gonzalo N, Fernández-Ortiz A, Macaya C, Escaned J. Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management. Open Heart 2018; 5:e000884. [PMID: 30487978 PMCID: PMC6241978 DOI: 10.1136/openhrt-2018-000884] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Fernando Macaya
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
| | - Pablo Salinas
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
| | - Nieves Gonzalo
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
| | - Antonio Fernández-Ortiz
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
| | - Carlos Macaya
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
| | - Javier Escaned
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
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31
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Adlam D, Alfonso F, Maas A, Vrints C. European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection. Eur Heart J 2018; 39:3353-3368. [PMID: 29481627 PMCID: PMC6148526 DOI: 10.1093/eurheartj/ehy080] [Citation(s) in RCA: 404] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/19/2017] [Accepted: 02/07/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- David Adlam
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Angela Maas
- Department of Cardiology, Women's Cardiac Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiaan Vrints
- University of Antwerp - Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
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32
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Tahmasebi F, Hurrell A, Ford A, Gupta M, Geindreau D, Pimenta D, O’Mahony C. Coronary artery dissection in the puerperium: A case report and literature review. Obstet Med 2018; 11:144-147. [PMID: 30214482 PMCID: PMC6134346 DOI: 10.1177/1753495x17740063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 09/27/2017] [Indexed: 11/16/2022] Open
Abstract
Spontaneous coronary artery dissection is a rare but important cause of acute coronary syndrome. Its relevance for women during the puerperium mandates awareness and understanding amongst obstetric healthcare professionals. The aetiology of the increased risk in pregnancy has not been fully elucidated, but include medial eosinophilic angitis, pregnancy-induced degeneration of collagen in conjunction with the stresses of parturition, and rupture of the vasa vasorum. The risk of mortality necessitates prompt diagnosis, usually by angiography. There is no one-size-fits-all treatment; management must be individualised according to haemodynamic status and affected vessel(s) and includes conservative management, percutaneous coronary intervention, or bypass grafting. Recovery complications include extension of the haematoma or false lumen, valvular pathology secondary to ischaemia, and sudden cardiac death. Close post-operative surveillance is mandatory. We present a 41-year-old lady with post-partum spontaneous coronary artery dissection, complicated by ischaemic papillary rupture and mitral regurgitation requiring valve replacement. Additionally, we present a literature review, including guidance on management and critical analysis of potential complications.
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Affiliation(s)
- Farshad Tahmasebi
- Obstetrics and Gynaecology,
Whipps
Cross University Hospital, London, UK
| | - Alice Hurrell
- Obstetrics and Gynaecology,
Whipps
Cross University Hospital, London, UK
| | - Amie Ford
- Bart's and The London School of Medicine
and Dentistry, London, UK
| | - Manish Gupta
- Obstetrics and Gynaecology,
Whipps
Cross University Hospital, London, UK
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Abstract
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.
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Ferrieri A, Buca D, Spadano S, Ricciardulli A, Liberati M, Petrini F, Maggiore SM. Spontaneous coronary artery dissection complicated by cardiac arrest in pregnancy. Minerva Anestesiol 2018; 84:1326-1327. [PMID: 29808975 DOI: 10.23736/s0375-9393.18.12869-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alessandro Ferrieri
- Department of Anesthesiology and Intensive Care, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Danilo Buca
- Department of Obstetrics and Gynecology, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Stefania Spadano
- Department of Anesthesiology and Intensive Care, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Alessandra Ricciardulli
- Department of Obstetrics and Gynecology, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynecology, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Flavia Petrini
- Department of Anesthesiology and Intensive Care, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Salvatore M Maggiore
- Department of Anesthesiology and Intensive Care, SS. Annunziata Hospital, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy -
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Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e523-e557. [PMID: 29472380 PMCID: PMC5957087 DOI: 10.1161/cir.0000000000000564] [Citation(s) in RCA: 716] [Impact Index Per Article: 119.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.
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Paratz ED, Kao C, MacIsaac AI, Somaratne J, Whitbourn R. Evolving management and improving outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD): a systematic review. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2018; 18:1-6. [PMID: 29750179 PMCID: PMC5941240 DOI: 10.1016/j.ijcha.2017.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/13/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is defined as SCAD occurring during pregnancy or within 3 months post-partum. Earlier systematic reviews have suggested a high maternal and foetal mortality rate. We undertook a structured systematic review of P-SCAD demographics, management and maternal and foetal outcomes. METHODS Case study identification was conducted according to PRISMA guidelines, with screening of all published P-SCAD cases not meeting pre-defined exclusion criteria. Of two hundred and seventy-three publications screened, one hundred and thirty-eight cases met inclusion criteria. Cases were allocated to one of three time periods; 1960-85 (twenty cases) reflecting early management of P-SCAD, 1986-2005 (forty-two cases) reflecting recent management, and 2006-16 (seventy-six cases), reflecting contemporary management. RESULTS The only significant demographic change in women experiencing P-SCAD over the last 50 years was an increasing proportion of primigravidas (p = 0.02). Management and outcomes, however, have altered significantly. Emergent angiography (p < 0.0001), reduced thrombolysis (p = 0.006) and increasingly conservative or percutaneous management (p < 0.0001) are associated with dramatic reductions in maternal mortality (85% in earliest reports to 4% in the last decade, p < 0.0001) and foetal mortality (50% in earliest reports to 0.0% in the last decade, p = 0.023). CONCLUSION This systematic review of temporal changes in presentation, management and outcomes of P-SCAD represents the widest range of variables analysed in the largest cohort of P-SCAD patients to date. In the setting of earlier coronary angiography and increasingly conservative management, maternal and foetal survival rates continue to improve.
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Affiliation(s)
| | - Chien Kao
- Department of Cardiology, St Vincent's Hospital, Melbourne, Australia
| | - Andrew I MacIsaac
- Department of Cardiology, St Vincent's Hospital, Melbourne, Australia
| | | | - Robert Whitbourn
- Department of Cardiology, St Vincent's Hospital, Melbourne, Australia
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Valappil SP, Iype M, Viswanathan S, Koshy AG, Gupta PN, Velayudhan RV. Coronary angioplasty in spontaneous coronary artery dissection-Strategy and outcomes. Indian Heart J 2018; 70:843-847. [PMID: 30580854 PMCID: PMC6306396 DOI: 10.1016/j.ihj.2018.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/23/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To study the clinical, angiographic and technical characteristics of patients with spontaneous coronary artery dissection (SCAD) undergoing percutaneous coronary intervention (PCI). METHODS This was a retrospective single center study where patients with angiographically confirmed SCAD undergoing PCI over a period of 4 years (2013-2017) were analyzed. We also sought to identify the clinical and angiographic predictors of procedural failure during PCI. RESULTS There were a total of 42 patients with angiographically confirmed SCAD during the study period of which 16 patients (38.1%) underwent PCI. 14 out of the 16 patients (87.5%) taken up for PCI had technical success. In all patients the lesion was initially attempted to cross with a floppy wire and if unsuccessful it was escalated to a hydrophilic wire and finally to a stiff wire The SCAD lesion was crossed with a floppy wire in 71.4% of patients, with a hydrophilic wire in 14.2% and a stiff wire in 7.1% of patients. Wire escalation was required in 5 patients (31.3%) and in 60% of cases there was a technical success after wire escalation. Presence of diabetes mellitus, hypertension, dyslipidemia, smoking, coexisting atherosclerosis, diffuse nature of the lesion, and baseline Thrombolysis in Myocardial Infarction (TIMI)≤2 flow did not predict procedural failure during PCI. CONCLUSION PCI in SCAD is associated with a fair rate of technical success in our population. Choosing an initial floppy wire and then escalating to a hydrophilic wire followed by a stiff wire is an optimal revascularization strategy.
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Affiliation(s)
- Sanjai Pattu Valappil
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala, 695011, India.
| | - Mathew Iype
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala, 695011, India
| | - Sunitha Viswanathan
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala, 695011, India
| | | | - Prabha Nini Gupta
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala, 695011, India
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Bitting CP, Zumwalt RE. Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature. J Forensic Sci 2017; 62:1389-1394. [PMID: 28168688 DOI: 10.1111/1556-4029.13436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 11/30/2022]
Abstract
Non-atherosclerotic spontaneous coronary artery dissection (NA-SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA-SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow-up) to invasive angiographic procedures. Rarely, NA-SCAD has recurred in another coronary artery, ranging hours to years later. We report NA-SCAD of the right coronary artery (RCA) in a 30-year old, 3-month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA-SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA-SCAD recurrence in a subsequent pregnancy.
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Affiliation(s)
- Casey P Bitting
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM.,Office of the Medical Investigator, Albuquerque, NM
| | - Ross E Zumwalt
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM.,Office of the Medical Investigator, Albuquerque, NM
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Joly JM, Bittner V. Advanced Imaging and Diagnostic Methods in the Assessment of Suspected Ischemic Heart Disease in Women. Curr Cardiol Rep 2016; 18:84. [PMID: 27443380 DOI: 10.1007/s11886-016-0767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although differences diminish with age, outcomes are overall worse for women compared to men who present with suspected acute coronary syndrome. The reasons for this discrepancy are multifactorial, including sex-related differences in atherosclerosis biology and fluid dynamics, as well as a premature conclusion by providers that chest pain must be noncardiac in the absence of obstructive coronary artery disease. In this review of existing literature, we explore the diverse differential diagnosis in this unique set of patients. Especially in women with persistent symptoms, absence of occlusive disease should prompt consideration for subangiographic plaque disruption, epicardial or microvascular endothelial dysfunction, transient neurohormonal imbalance predisposing to Takotsubo cardiomyopathy or spontaneous coronary artery dissection, underlying systemic inflammatory conditions, thromboembolic disease, myocarditis, and sequelae of congenital heart disease. As always, a thorough history and attentive physical exam will help guide further work-up, which in many cases may warrant noninvasive imaging, such as contrast-enhanced echocardiography, cardiac magnetic resonance imaging, or positron emission tomography, with their respective means of measuring myocardial perfusion and myocardial tissue pathology. Lastly, intracoronary imaging such as intravascular ultrasound and optical coherence tomography and invasive diagnostic methods such as coronary reactivity testing continue to add to our understanding that what appear to be atypical presentations of ischemic heart disease in women may in fact be typical presentations of pathologic cousin entities that remain incompletely defined.
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Affiliation(s)
- Joanna M Joly
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 701 19th Street South, LHRB 310, Birmingham, AL, 35294, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 701 19th Street South, LHRB 310, Birmingham, AL, 35294, USA.
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