Characteristic findings of acute spontaneous coronary artery dissection by cardiac computed tomography

Angiographic patterns in spontaneous coronary artery dissection: novel diagnostic insights

INTRODUCTION

Spontaneous coronary artery dissection (SCAD) is a rare but well-recognized cause of acute coronary syndrome, especially important in women. Invasive coronary angiography (ICA) is the fundamental diagnostic technique for the confirmation of SCAD. Knowing the angiographic patterns suggestive of SCAD is essential for the correct identification of patients with this entity.

AREAS COVERED

In this narrative review, the main angiographic characteristics of SCAD lesions as detected by ICA are presented and discussed.

EXPERT OPINION

In addition to the specific angiographic classification of SCAD, several authors have described complementary angiographic patterns suggestive of SCAD. Knowledge and correct identification of these angiographic patterns is essential for the correct diagnosis of patients with clinical suspicion of SCAD.

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

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

Spectrum of Ischemic Heart Disease Throughout a Woman's Life Cycle

Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in both genders; however, young women fare the worst, likely reflecting the more complex spectrum of IHD in women when compared to men. Substantial sex-based differences exist in the underlying risk factors, risk enhancers, presentation, diagnosis, and pathophysiology of IHD that are mainly attributed to the influence of female sex hormones. This article reviews the spectrum of IHD including obstructive epicardial coronary artery disease (CAD), myocardial infarction with no obstructive coronary artery disease, ischemia with no obstructive coronary artery disease, spontaneous coronary artery dissection, coronary microvascular dysfunction, vasospastic angina, and coronary thrombosis/embolism that occur in women throughout various stages of their life cycle. We aim to update clinicians on the diagnosis and management of these various types of IHD and highlight where further randomized controlled studies are needed to determine optimal treatment and inform guideline-directed medical therapy.

Spontaneous coronary artery dissection: An underrecognized cause of ACS

ABSTRACT

Spontaneous coronary artery dissection (SCAD) is an underrecognized form of nonatherosclerotic acute coronary syndrome, mostly occurring in younger female patients. The knowledge base about the diagnosis and management of SCAD has grown over the past decade, but gaps remain in how best to approach this disease. This article reviews the research on the prevalence, presentation, and management of SCAD.

Spontaneous coronary artery dissection: an overview

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

Current challenges in treatment and management of spontaneous coronary artery dissection

Though an infrequent cause of acute coronary syndrome, spontaneous coronary artery dissection is an increasingly recognized cardiovascular condition predominantly seen in middle-aged females. Its pathophysiology is defined by separation of coronary arterial wall layers which cause acute coronary syndrome-like presentations with relatively high recurrence rates. Overall, there is a lack of reported literature and understanding of the short- and long-term management for spontaneous coronary artery dissection. Therapeutic approaches include, but are not limited to, percutaneous coronary intervention, surgical revascularization, antithrombotic therapy, and beta-blocker therapy. There is a significant absence of randomized control trials to help guide both interventional and medical management for spontaneous coronary artery dissection. This review is aimed to review the current literature regarding risk factors and considerations for the short- and long-term management of spontaneous coronary artery dissection.

Assessment of extra-coronary peripheral arteriopathy in spontaneous coronary dissection: state of the art in non-invasive imaging techniques and future perspectives

Spontaneous coronary artery dissection (SCAD) has been recognized as an important cause of acute coronary syndrome in women ≤ 50 years old, and up to 43% of pregnancy-associated myocardial infarction. SCAD has a strong association with extra-coronary arteriopathies, including either more common entities such as dissections, intracranial or other aneurysms, and extra-coronary and coronary arterial tortuosity or less common inherited vascular disorders such as Ehlers-Danlos syndrome, Marfan syndrome, and Loeys-Dietz syndrome, leading to the conclusion that systemic arterial disorders may underlie SCAD. Fibromuscular dysplasia is the most common extra-coronary vascular abnormality identified among these patients, also sharing a common genetic variant with SCAD. The American Heart Association, in a scientific statement regarding the management of SCAD, recommends that patients with SCAD should undergo additional evaluation with imaging techniques including either computed tomography angiography (CTA) or magnetic resonance angiography (MRA). MRA has been shown to have sufficient diagnostic accuracy in identifying extra-coronary arterial abnormalities, almost equal to CTA and conventional angiography. The aim of this review is to appraise the most recent important evidence of extra-coronary arteriopathy in the setting of SCAD and to discuss the strengths and weaknesses of various non-invasive imaging methods for screening of extra-coronary arteriopathies in patients with SCAD.

A Tale of Two Evils: Iatrogenic Propagation of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic intimal separation of the coronary arterial wall. While poorly understood, its mechanism confers higher prevalence in younger females, and it is responsible for 25% of acute coronary syndromes (ACS) in women under 50 years of age. SCAD is primarily diagnosed via coronary angiography; however, intraluminal contrast injection and percutaneous coronary interventions (PCI) are associated with an increased risk of propagation and extension of the dissection leading to increased risk of morbidity and mortality. We present the case of a 48-year-old female with multivessel SCAD and subsequent iatrogenic dissection following contrast injection requiring multiple PCI for medical treatment of refractory cardiac angina.

TyG index as a predictor of spontaneous coronary artery dissection in young women

OBJECTIVE

Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening pathology and cases are especially seen in women under 50 years of age and with relatively fewer cardiovascular risk factors. Although risk factors facilitating the development of SCAD have been defined in the literature, modifiable risk factors remain unclear. In this study, it was aimed to investigate the relationship between the triglyceride glucose index (TyG) and the development of SCAD in the population of young women.

METHODS

The results of 281 patients were analyzed and compared with each other in terms of clinical, demographic, laboratory parameters, and coronary angiography results.

RESULTS

The mean age was 45 years and all of them were female. When the groups were compared, the TyG and inflammatory parameters were higher in the SCAD group (p < 0.001). When these two groups with low cardiovascular risk factors were compared in logistic regression analysis, high TyG was found to be an independent predictor of SCAD development in young women (p < 0.001).

CONCLUSION

As a result, our study shows that the development of these non-atherosclerotic conditions can be predicted by simple biochemical tests in young women with low atherosclerotic cardiovascular risk factors.

Spontaneous coronary artery dissection: the emerging role of coronary computed tomography

Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome and myocardial infarction, more frequent among young women. Invasive coronary angiography (ICA) is the gold standard for the diagnosis of SCAD, although the risk of propagating dissection flap is considerable. Therefore, coronary computed tomography angiography (CCTA) is an emerging alternative modality to diagnose SCAD with the advantage of being a non-invasive technique. Clinicians should be aware of the predisposing conditions and pathophysiology to raise the pre-test probability of SCAD and select the most appropriate diagnostic tools. In recent times, improvements in spatial and temporal resolution and the use of semi-automated software providing quantitative assessment make CCTA a valid alternative to ICA also for the follow-up. Moreover, CCTA may be helpful to screen and evaluate extra-coronary arteriopathies closely related to SCAD. In this review, we illustrate the current and the potential role of CCTA in the diagnosis of SCAD, highlighting advantages and disadvantages of this imaging modality compared to ICA.

Recurrent spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and is more prevalent in pregnancy. The disease is being increasingly appreciated and diagnosed with the development and application of coronary angiography and intravascular imaging. Recurrent spontaneous coronary artery dissection (R-SCAD) is relatively common, with recurrence rates ranging from 8 to 27%. R-SCAD usually involves anatomical sites different from the original SCAD lesion and can cause MI, ventricular arrhythmias, and cardiogenic shock. This study aims to conduct a comprehensive review of R-SCAD to identify early risk factors and guide prevention policies and interventions. In addition, the risk of R-SCAD in subsequent pregnancies in women with a history of SCAD is discussed.

Cardiovascular disease in women: A review of spontaneous coronary artery dissection

Research has demonstrated the disproportionate quality of care for women with cardiovascular disease. These findings have prompted a renewed focus on cardiovascular disease awareness and disease prevention in women. Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and sudden death that primarily affects women. ongoing research has led to improved diagnostic capabilities and changes in approaches to initial and long-term management most importantly this research has provided evidence that SCAD is more common than previously thought and must be evaluated and treated differently from atherosclerotic MI. The difference between SCAD and atherosclerotic MI is highlighted in high rates of recurrent disease, gender distribution, association with exogenous hormones, pregnancy, migraine, physical and emotional stress triggers, concurrent systemic arteriopathies, and connective tissue disease. In this review, we provide updated insights and a summary of the epidemiology, risk factors, clinical presentation, diagnosis, treatment options, prognosis, and recurrence prevention of SCAD. We aim to provide a review of SCAD as a focus on cardiovascular disease awareness and disease prevention in women.

MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment

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.

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.

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

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

Spontaneous Coronary Artery Dissections: A Systematic Review

Myocardial infarction with nonobstructive coronary artery disease due to spontaneous coronary artery dissection (SCAD) accounts for 5–8% of acute coronary syndrome (ACS) presentations. The demographic characteristics, risk factors, and management of patients with SCAD differ from those with atherosclerotic disease. The objective of this review is to provide a contemporary understanding of the epidemiology, pathophysiology, clinical presentation, and management of SCAD.

Rationale and design of the BA-SCAD (Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection) randomized clinical trial

INTRODUCTION Y OBJECTIVES

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Most patients are empirically treated with beta-blockers and antiplatelet drugs. The Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection (BA-SCAD) is an academic, pragmatic, prospective, randomized, open-label, blinded-endpoint clinical trial, performed under the auspices of the Spanish Society of Cardiology, to assess the efficacy of pharmacological therapy in patients with SCAD.

METHODS

Using a 2 x 2 factorial design, 600 patients will be randomized (1:1/1:1) to: a) beta-blockers (yes/no) and b) "short" (1 month) vs "prolonged" (12 months) antiplatelet therapy. Only patients with preserved left ventricular ejection fraction will be randomized to beta-blockers (yes/no) because patients with reduced left ventricular ejection fraction will receive beta-blockers according to current guidelines. Similarly, only conservatively managed patients (ie, no coronary intervention) will be randomized to the antiplatelet stratum, as patients requiring coronary interventions will receive 1-year dual antiplatelet therapy. The primary efficacy endpoint includes a composite of death, myocardial infarction, stroke, coronary revascularization, recurrent SCAD, and unplanned hospitalization for acute coronary syndrome or heart failure at 1 year. The primary safety endpoint will be bleeding. All patients will be clinically followed up yearly. A comprehensive set of additional substudies (clinical, imaging, revascularization, biomarkers, inflammatory, immunologic, pharmacogenetics, and genetic) will be conducted to ensure a holistic view of this unique and challenging clinical entity.

CONCLUSIONS

The results of the BA-SCAD randomized clinical trial will advance our knowledge in the treatment of patients with SCAD. The study was registered at ClinicalTrials.gov (Identifier: NCT04850417).

Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA): a Review of the Present and Preview of the Future

PURPOSE OF REVIEW

The syndrome of myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is not uncommon and has multiple potential coronary etiologies. With the use of more sensitive cardiac biomarkers and advanced cardiovascular imaging, MINOCA presentations have gain increasing attention among researchers and cardiologists. Despite the presence of a myocardial infarction and elevated future risk, many patients are sent home with little or no cardio-protective treatment and no explanation for their symptoms. In this review, we emphasized the importance of MINOCA treatment based on the underlying etiology.

RECENT FINDINGS

As there are multiple pathophysiological mechanisms potentially involved in MINOCA, it should be considered a working diagnosis until there is a better understanding regarding the underlying cause. It is critical to use multimodality imaging when treating patients with MINOCA to help determine the underlying etiology and rule out mimics of MINOCA, so that therapies appropriate to the etiology can be provided. A more systematic approach to managing patients with MINOCA should result in better treatment and an improved prognosis for these patients.

Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review

Over the past decade, spontaneous coronary artery dissection (SCAD) has emerged as an important cause of myocardial infarction, particularly among younger women. The pace of knowledge acquisition has been rapid, but ongoing challenges include accurately diagnosing SCAD and improving outcomes. Many SCAD patients experience substantial post-SCAD symptoms, recurrent SCAD, and psychosocial distress. Considerable uncertainty remains about optimal management of associated conditions, risk stratification and prevention of complications, recommendations for physical activity, reproductive planning, and the role of genetic evaluations. This review provides a clinical update on the diagnosis and management of patients with SCAD, including pregnancy-associated SCAD and pregnancy after SCAD, and highlight high-priority knowledge gaps that must be addressed.

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.