Spontaneous coronary artery dissection: update 2019

Spontaneous coronary artery dissection and fibromuscular dysplasia: insights into recent developments

Spontaneous coronary artery dissection (SCAD), an uncommon cause of acute coronary syndrome, continues to be a poorly understood disease predominantly affecting females. It is characterized by an abrupt separation in the coronary arterial wall due to intramural bleeding. Fibromuscular dysplasia (FMD) is a non-atherosclerotic arteriopathy manifesting in medium and small-sized arteries. It is a concomitant disease found among SCAD patients. In some studies, FMD prevalence in SCAD patients ranges between 25%-86%, which can be explained through varying screening techniques or modalities. The potential association has been elucidated in some studies; notably, not only has a genetic link been recently delineated between SCAD and FMD, but there is data to suggest that FMD not only can predispose to SCAD but can also be a potential predictor of its recurrence. However, a clear-cut correlation between the two has still not been established due to conflicting reports in the literature. To further dive into its pathology, it is crucial to highlight the importance of systematic screening in SCAD in order to identify associated risk factors and to be used as a method of FMD detection in such patients. Together, the two pathologies pose unique challenges in understanding its pathophysiology, diagnosis and management, as there is no clear evidence of a definitive treatment plan for patients with SCAD and FMD. A potentially beneficial modality of management is physical exercise, which is currently understudied in the long-term approach to treatment for patients with concomitant SCAD and FMD. Limited research in this field brings disadvantages to the understanding of the association between these two diseases, in order to give rise to better management recommendations. This mini-review aims to highlight the recent developments in the association between SCAD and FMD, its potential genetic association and some insights in screening, diagnosis, and management.

MINOCA: A Working Diagnosis

Cases of patients presenting with myocardial infarction (MI) without angiographic obstructive CAD are not trivial and have significant prevalence. "The Fourth Universal Definition of MI" (4UDMI) published in 2018 introduced MI with non-obstructive coronary arteries (MINOCA). The new section was of great importance as it validated the diagnosis by defining its criteria and recognizing its presence in the community and the need for further investigation. Given the nature of the diagnosis of MINOCA, coronary angiography provides limited information about prognosis and risk stratification for future major adverse cardiovascular events (MACE). Thus, additional imaging to understand the underlying etiology of MINOCA in conjunction with a better understanding of prognostic factors is necessary to expand on the current guidelines and aid in screening for possible complications, risk of MACE, and all-cause mortality. Discerning the etiology of the presentation is crucial, and physiologic studies, as well as additional imaging, are an important part of this evaluation. These modalities include intravascular studies such as optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), and imaging in the form of cardiac CT (CCT) and cardiac MRI (CMR). This step is essential to target treatment regimens more efficiently. The purpose of promoting multiple imaging modalities beyond traditional angiography is to address the working MINOCA diagnosis, with the finality of identifying the specific ischemic pathophysiology. MINOCA has multiple causative mechanisms, making it a heterogeneous collection of etiologies, resulting in acute MI: atherosclerotic, and non-atherosclerotic. This literature revision demonstrates that MINOCA prevalence and mortality are not trivial, and the diagnosis affects quality of life. MINOCA presents a definitive risk of MACE without proper stratification and targeted medical therapy. Several prognostic factors of morbidity and mortality in MI-CAD patients have been identified to correlate with MINOCA patients, especially inflammatory markers. MINOCA is not an exclusion diagnosis but a working diagnosis for which further imaging studies should be performed.

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.

[STEMI mimics : ST elevations on ECG: alternative diagnoses to acute coronary occlusion]

BACKGROUND

The electrocardiogram (ECG) is an integral part of basic emergency medical diagnosis and preoperative evaluation. In cases of ST elevation myocardial infarction (STEMI) immediate treatment is mandatory after correlation of ischemic symptoms with the ECG pattern. However, there are also ECG patterns that can imitate STEMI, possibly resulting in the true underlying diagnosis being missed and inappropriate therapy being initiated.

OBJECTIVES

This paper provides an overview of the most important diagnoses that can imitate STEMI on ECG.

MATERIAL AND METHODS

A literature search was carried out to determine the most important differential diagnoses of ST elevation on ECG. These STEMI mimics are discussed in detail and their relevance for emergency medicine is explained.

RESULTS

This article provides an overview of differential diagnoses that should be known in emergency medicine when assessing an ECG with ST elevations.

CONCLUSION

Good knowledge of the ECG patterns presented here can support decision-making in emergency medicine.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS

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

DISSEMINATION OF RESULTS

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

REGISTRATION DETAILS

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

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.

Case report: Spontaneous coronary artery dissection in a man with Ehlers–Danlos syndrome

Background

Spontaneous coronary artery dissection (SCAD), as a medical emergency, represents one of the non-atherosclerotic causes of an acute coronary syndrome (ACS). It often occurs in young and middle-aged females and is a rarity among male patients. Yet, it is easily misdiagnosed or missed even though it has one of the highest in-hospital mortality rates.

Case summary

Here, we present a young male patient admitted to the emergency department of our hospital due to a complaint of acute chest pain. During his hospitalization, we utilized several tools, including imaging modalities, genetic analyses, and clinical strategies, to ensure a proper diagnosis and management of the patient. The results indicated that the patient suffered from SCAD, as well as vascular Ehlers–Danlos syndrome (vEDS). Unfortunately, the patient died of SCAD-related sudden cardiac death (SCD) on the ninth day before the DNA analysis results were obtained. Despite a global effort and huge progress in the clinical characterization of SCAD, as well as patients’ assessments, its pathophysiology remains poorly understood, with a significant recurrence risk and no specific disease-modifying therapy.

Conclusion

Vascular Ehlers–Danlos syndrome, as an inherited connective tissue disorder characterized by congenital connective tissue dysplasia, is a rare and particularly challenging monogenetic disease. It can cause life-threatening changes, including arterial dissections and ruptures, and lead to early death due to COL3A1 pathogenic variants. It is also a rare cause of SCAD. Currently, the gold standard for SCAD diagnosis is coronary angiography (CAG).

Spontaneous Coronary Artery Dissection and Evidence-Based Medicine

Spontaneous coronary artery dissection (SCAD) is a relatively newly diagnosed area, and evidence-based medicine (EBM) standards are emerging and currently include an aspirin, β blocker, clopidogrel, angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker for patients with hypertension, vascular abnormality imaging, and cardiac rehabilitation. Because SCAD is an uncommon condition, many providers are unfamiliar with EBM treatment standards which could affect the implementation of recommended treatment. This study documented the frequency of failure to meet EBM SCAD treatment standards and factors contributing to conformance failure. Patients who presented to a tertiary referral hospital from January 1, 2005, to July 6, 2020, were included. The electronic medical record was reviewed for EBM treatment. Patients who did not meet the criteria of EBM were contacted by phone for a phone interview. The study period included 118 patients with SCAD, 3 of whom (2.5%) died and were not eligible for this study. In the final cohort of 115 patients, the average age was 55 years, female gender (97%) and EBM standards were met in 30%. Of patients who participated in the phone interview, 38 (33%) reported frustration with SCAD misdiagnosis (39%), inadequate mental health resources (37%), and communication failure regarding the need for cardiologist follow-up (26%). Cardiac rehabilitation use was impacted by location, time of day, availability, and cost. The most common medication-limiting factor for β-blocker usage was fatigue (15%). Most (59%) patients did not undergo fibromuscular dysplasia imaging. In conclusion, in this 15-year SCAD study from a single tertiary care hospital SCAD registry, only 30% met the current EBM for SCAD. Unique solutions that are both patient-informed and evidence-driven are needed to achieve the best clinical outcomes.

Spontaneous Coronary Artery Dissection: Rediscovering an Old Cause of Myocardial Infarction

Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.

Distribution Characteristics of ST-Segment Elevation Myocardial Infarction and Non-ST-Segment Elevation Myocardial Infarction Culprit Lesion in Acute Myocardial Infarction Patients Based on Coronary Angiography Diagnosis

This research was aimed at exploring the application value of coronary angiography (CAG) based on a convolutional neural network algorithm in analyzing the distribution characteristics of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) culprit lesions in acute myocardial infarction (AMI) patients. Methods. Patients with AMI treated in hospital from June 2019 to December 2020 were selected as subjects. According to the results of an echocardiogram, the patients were divided into the STEMI group (44 cases) and the NSTEMI group (36 cases). All patients received CAG. All images were denoised and edge detected by a convolutional neural network algorithm. Then, the number of diseased vessels, the location of diseased vessels, and the degree of stenosis of diseased vessels in the two groups were compared and analyzed. Results. The number of patients with complete occlusion (3 cases vs. 12 cases) and collateral circulation (5 cases vs. 20 cases) in the NSTEMI group was significantly higher than that in the STEMI group, and the difference was statistically significant, P < 0.05. There was a statistically significant difference in the number of lesions between the distal LAD (1 case vs. 10 cases) and the distal LCX (4 cases vs. 11 cases), P < 0.05. There was a statistically significant difference in the number of patients with one lesion branch (1 vs. 18) and three lesion branches (25 vs. 12) between the two groups, P < 0.05. The image quality after the convolution neural network algorithm is significantly improved, and the lesion is more prominent. Conclusion. The convolutional neural network algorithm has good performance in DSA image processing of AMI patients. STEMI and NSTEMI as the starting point of AMI disease analysis to determine the treatment plan have high clinical application value. This work provided reference and basis for the application of the convolutional neural network algorithm and CAG in the analysis of the distribution characteristics of STEMI and NSTEMI culprit lesions in AMI patients.

Optical Coherence Tomography-OCT for Characterization of Non-Atherosclerotic Coronary Lesions in Acute Coronary Syndromes

Cardiovascular diseases are the main cause of death worldwide, with coronary artery disease being the predominant underlying etiology. The most prevalent coronary lesions are represented by the atherosclerotic plaques, in more than 85% of cases, but there are several other non-atherosclerotic lesions such as spontaneous coronary artery dissection and/or hematoma and spontaneous recanalization of coronary thrombus, which are less common, approximately 5% of cases, but with similar clinical manifestations as well as complications. There are insufficient data regarding the pathological mechanism, true prevalence and optimal treatment of these kind of coronary lesions. Optical coherence tomography (OCT) is an intracoronary imaging technique, developed in order to overcome the diagnostic limitations of a standard coronary angiography and has an extremely high resolution, similar to that of a usual histological evaluation of a biopsy sample, thus, OCT provides a histological-like information, but in a in vivo environment. The aim of this article is to review the current knowledge regarding non-atherosclerotic coronary lesions, with an emphasis on the importance of OCT for optimal identification, characterization of pathogenic mechanisms and optimal treatment selection.

When "Wait and See" may be the Best Option: Two Case Reports of Left Main Artery Spontaneous Dissection

INTRODUCTION

Spontaneous coronary artery dissection (SCAD) is frequently underdiagnosed, and the most appropriate management is unknown, particularly in high-risk anatomical subsets.

CASE REPORTS

Two cases of females in their 60-70s with few cardiovascular risk factors or relevant past medical history, who presented acute myocardial infarction, have been presented. Both were submitted to invasive coronary angiography, with a suspicion of SCAD in both cases, which was later supported by coronary computed tomography angiography (CCTA). They were managed conservatively under close monitoring, with a favorable outcome. Repeated CCTA showed significant improvement, and both patients remained asymptomatic and free from complications 6 and 12 months after the initial event.

CONCLUSION

The recognition of spontaneous coronary artery dissection is essential for the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in those patients are suboptimal and conservative management is probably the best option, even in patients with high-risk anatomy.

The Self Sabotaging Vessel: A Case Report and Literature Review of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndrome. Despite the recent advances in the management of cardiovascular diseases, the diagnoses and management of SCAD remain a dilemma. It has been described to majorly affect females of childbearing age, immediately post-partum or on oral contraceptives. Recent cases have also identified underlying connective tissue disease as a risk factor. Since its discovery, only a limited number of cases affecting males have been reported in the literature. This makes our case unique. In this, we present a 31-year-old male without any traditional risk factors who presented with atypical chest pain. Electrocardiogram showed ST-segment changes with echocardiogram revealing apical left ventricular akinesis. A diagnostic left heart catheterization showed multiple lumens in the distal left anterior descending artery (LAD). The patient was managed conservatively and discharged home on guideline-directed medical therapy.

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

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

Characteristics, Management, and Prognosis of Spontaneous Coronary Intramural Hematoma

Spontaneous coronary intramural hematoma (SCIH) was one type of spontaneous coronary artery dissection without obvious intimal tear, which is easy to misdiagnose. We aimed to study the characteristics, management, and prognosis of SCIH in our center. All the SCIH patients (n = 30) diagnosed by coronary angiography from January 1, 2012 to December 31, 2018 were enrolled. The demographic characteristics, history, therapy, and follow-up were collected. The mean age of the patients was 51.8 ± 9.5 years. Most of the patients were females (66.7%) with hypertension. Patients with diffuse lesion, focal lesion, and multiple vessels were 70%, 13.3%, and 16.7%, respectively. Conservative treatment was the first choice (76.7%). The mean follow-up time was 29.3 ± 13.5 months. None of the patients had unplanned readmission due to worsening symptoms. Nine patients underwent coronary artery computed tomography reexamination after 10.3 ± 7.5 months, which showed complete recovery of SCIH. Eight patients were hospitalized for coronary angiography 6.4 ± 4.7 months later, which did not show any sign of SCIH. Spontaneous coronary intramural hematoma was most common in post-menopausal women with hypertension. Possibly, antiplatelet drugs should be avoided in SCIH. Waiting for the hematoma to heal was preferable and had a good prognosis.

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.

Differential miRNAs in acute spontaneous coronary artery dissection: Pathophysiological insights from a potential biomarker

Background

Spontaneous Coronary Artery Dissection (SCAD) is an important cause of acute coronary syndromes, particularly in young to middle-aged women. Differentiating acute SCAD from coronary atherothrombosis remains a major clinical challenge.

Methods

A case-control study was used to explore the usefulness of circulating miRNAs to discriminate both clinical entities. The profile of miRNAs was evaluated using an unbiased human RT-PCR platform and confirmed using individual primers. miRNAs were evaluated in plasma samples from acute SCAD and atherothrombotic acute myocardial infarction (AT-AMI) from two independent cohorts; discovery cohort (SCAD n = 15, AT-AMI n = 15), and validation cohort (SCAD n = 11, AT-AMI n = 41) with 9 healthy control subjects. Plasma levels of IL-8, TGFB1, TGBR1, Endothelin-1 and MMP2 were analysed by ELISA assays.

Findings

From 15 differentially expressed miRNAs detected in cohort 1, we confirmed in cohort 2 the differential expression of 4 miRNAs: miR-let-7f-5p, miR-146a-5p, miR-151a-3p and miR-223-5p, whose expression was higher in SCAD compared to AT-AMI. The combined expression of these 4 miRNAs showed the best predictive value to distinguish between both entities (AUC: 0.879, 95% CI 0.72–1.0) compared to individual miRNAs. Functional profiling of target genes identified an association with blood vessel biology, TGF-beta pathway and cytoskeletal traction force. ELISA assays showed high plasma levels of IL-8, TGFB1, TGFBR1, Endothelin-1 and MMP2 in SCAD patients compared to AT-AMI.

Interpretation

We present a novel signature of plasma miRNAs in patients with SCAD. miR-let-7f-5p, miR-146a-5p, miR-151a-3p and miR-223-5p discriminate SCAD from AT-AMI patients and also shed light on the pathological mechanisms underlying this condition.

Funding

Spanish Ministry of Economy and Competitiveness (MINECO): Plan Nacional de Salud SAF2017-82886-R, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Fundación BBVA a equipos de Investigación Científica 2018 and from Caixa Banking Foundation under the project code HR17-00016 to F.S.M. Instituto de Salud Carlos III (AES 2019): PI19/00565 to F.R, PI19/00545 to P.M. CAM (S2017/BMD-3671-INFLAMUNE-CM) from Comunidad de Madrid to FSM and PM. The UK SCAD study was supported by BeatSCAD, the British Heart Foundation (BHF) PG/13/96/30608 the NIHR rare disease translational collaboration and the Leicester NIHR Biomedical Research Centre.

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.

Role of Coronary CT Angiography in Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is more common than previously thought and is present in up to 4% of patients presenting with acute coronary syndrome. SCAD predominantly occurs in relatively young women and is an important cause of myocardial infarction in young patients without traditional risk factors of atherosclerotic coronary artery disease. There have been substantial improvements in spatial and temporal resolution and reduction in ionizing radiation dose with new generation scanners. The risk of dissection propagation with an invasive coronary angiogram, improved CT scanner parameters, and predominantly conservative management of SCAD make coronary CT angiography a useful noninvasive imaging modality for the assessment of SCAD. © RSNA, 2020.

Spontaneous Coronary Artery Dissection of the Left Main Coronary Artery

Heart attacks in young populations are frequently misdiagnosed as reflux disease or anxiety. Spontaneous coronary artery dissection (SCAD) is a coronary artery disease that classically manifests around the age of 45 years and has a fatal outcome if missed. Since it was first described in 1931, our understanding of SCAD has evolved tremendously, particularly with the advent of advanced coronary angiography. Electrocardiograms can show abnormality in the ST-segment, with an elevation of cardiac damage markers. The involvement of the coronary arteries is variable. The left main coronary artery is frequently reported as the main culprit. We are hereby reporting a case of SCAD in a young woman who presented with a heart attack. Particularly, her age is younger than the reported cases, cardiac catheterization revealed a left main artery dissection with a thrombolytic extension, and her complicated case was managed with coronary artery bypass and heart transplantation.

Three broken vessels in a peripartum patient: a rare case report of spontaneous triple vessel coronary artery dissection

Background

Spontaneous coronary artery dissection (SCAD) is a frequently underdiagnosed entity that carries a significant risk of morbidity and mortality. Spontaneous coronary artery dissection is increasingly recognized as an important cause of acute coronary syndrome (ACS) and, the majority of SCAD patients are young healthy women.

Case summary

A 23-year-old female G5P4 presented to the emergency room for severe sub-sternal chest pain, associated with shortness of breath. Past medical history was significant for pre-eclampsia. Initial electrocardiogram was remarkable for ST depressions in V5–V6 with inverted T waves to V1–V2. Troponin I was elevated to 1.13 ng/mL. Two-dimensional echo showed reduced left ventricular function with an ejection fraction of 40%. Cardiac catheterization showed triple vessel dissection involving the left main trunk extending into mid-left anterior descending and dissection extending from ostium of left circumflex artery into large first obtuse marginal branch. She was started on aspirin and heparin. After 48 h she was loaded with clopidogrel. Computed tomography angiography of head, neck, abdomen, and pelvis showed findings compatible with fibromuscular dysplasia. She was haemodynamically stable and symptom free and did not want surgery. She was recommended to continue dual antiplatelet therapy for 12 months and subsequently aspirin and beta blocker only lifelong.

Discussion

Spontaneous coronary artery dissection is a rare condition which is underdiagnosed. A thorough history and high degree of suspicion is required to diagnose in a timely manner and it should be high on differential in a postpartum female presenting with signs and symptoms of ACS.

Mechanisms of myocardial infarction with nonobstructive coronary atherosclerosis: a multifaceted play of different actors with guarded prognosis

PURPOSE OF REVIEW

Myocardial infarction (MI) with nonobstructive coronary atherosclerosis (MINOCA) on invasive angiography (stenosis severity <50%) is a heterogenous clinical entity with a prevalence between 6 and 8% of all MI. Whereas the long-term prognosis of MINOCA is not benign, the identification of its underlying mechanism is critical for appropriate risk stratification and tailored secondary prevention strategies.

RECENT FINDINGS

The current review summarizes the contemporary data on the mechanisms, diagnosis, management strategies and outcomes of MINOCA.

SUMMARY

MINOCA is a relatively common form of MI with guarded prognosis. The use of additional diagnostic tests (particularly intracoronary imaging and cardiac magnetic resonance) is paramount to determine the exact cause of MINOCA and implement tailored medical interventions.

Multivessel spontaneous coronary artery dissection in a patient after mild COVID-19: A case report

Coronavirus disease 2019 (COVID-19) is characterized by heterogeneity of possible cardiovascular manifestations. Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, the development of which in patients with COVID-19 has been described and studied insufficiently. A 35-year-old male patient presented to our hospital with an acute coronary syndrome a few weeks after mild COVID-19. According to coronary angiography, a dissection of ramus intermedius was detected. Successful stenting was performed. Subsequently, the patient had relapses of chest pain, which led to two repeated coronary angiographies. The patient had been diagnosed with consecutive dissections of right coronary artery and distal branch of ramus intermedius. Repeated stenting of dissected segments of right coronary artery and ramus intermedius was not performed. Afterward, the patient’s condition remained stable and he was successfully discharged. One of the main pathophysiological mechanisms of cardiovascular complications in COVID-19 is probably the virus-triggered hyperinflammation and massive release of cytokines. A systemic inflammatory response may initiate inflammation of the vascular wall and other target tissues. The results of histological studies confirm the direct infection of endothelial cells 2019-nCoV with the development of diffuse endothelial inflammation (endotheliitis). It is possible that in patients with a genetic predisposition to artery dissection, COVID-19 may be a trigger of spontaneous coronary artery dissection.