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

Spontaneous Coronary Artery Dissection: An Updated Comprehensive Review

Spontaneous coronary artery dissection (SCAD) is defined as a non-iatrogenic, non-traumatic separation of the coronary artery wall, which has gained considerable recognition as an important cause of acute coronary syndrome. Despite the emerging evidence, it is still frequently missed and requires a high index of suspicion, as failure to accurately identify SCAD promptly could prove fatal. SCAD is most prevalent among middle-aged women, although it can also be found in men and postmenopausal women. Risk factors of SCAD include exogenous hormone use, physical and emotional stressors, pregnancy, and several inflammatory and connective tissue disorders. COVID-19 also contributes to the prevalence of SCAD. SCAD is classified into four main types based on the angiographic findings - type 1, type 2, type 3, and type 4. The gold standard for diagnosis is coronary angiography; however, intracardiac imaging is useful if diagnostic doubts persist. Despite the increasing recognition of this disease, there is a paucity in the guidelines on the management of SCAD. Management may be conservative, medical, or interventional. Cardiac rehabilitation is also necessary in the management of patients with SCAD. In light of the gaps in evidence, the authors aim to provide a comprehensive review of the existing literature, outlining the pathophysiology, classification, and, most importantly, the evidence and pitfalls circulating diagnosis, acute, and long-term management of SCAD.

A Case of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is the development of an intramural hematoma that causes a false lumen to form, leading to occlusion and ischemia. It is a rare but separate pathologic cause of acute coronary syndrome, more commonly occurring in females and often associated with underlying vascular conditions. Definitive diagnosis requires invasive coronary angiography. Management is similar to that of myocardial infarction caused by atherosclerosis; however, the majority of SCADs are managed conservatively, as stenting often leads to worse outcomes. Diagnostic and management strategies are primarily based on consensus, with minimal randomized control trials or prospective analyses available to guide patient care.

A review of the risk and precipitating factors for spontaneous coronary artery dissection

Introduction

Spontaneous coronary artery dissection (SCAD) accounts for 1%-4% of cases of acute coronary syndrome (ACS). SCAD is caused by separation occurring within or between any of the three tunics of the coronary artery wall. This leads to intramural hematoma and/or formation of false lumen in the artery, which leads to ischemic changes or infarction of the myocardium. The incidence of SCAD is higher in women than in men, with a ratio of approximately 9:1. It is estimated that SCAD is responsible for 35% of ACS cases in women under the age of 60. The high frequency is particularly observed during pregnancy and in the peripartum period (first week). Traditional risk factors are rare in patients with SCAD, except for hypertension. Patients diagnosed with SCAD have different combinations of risk factors compared with patients who have atherosclerotic changes in their coronary arteries. We presented the most common so-called "non-traditional" risk factors associated with SCAD patients.

Risk factors and precipitating disorders which are associated with SCAD

In the literature, there are few diseases frequently associated with SCAD, and they are identified as predisposing factors. The predominant cause is fibromuscular dysplasia, followed by inherited connective tissue disorders, systemic inflammatory diseases, pregnancy, use of sex hormones or steroids, use of cocaine or amphetamines, thyroid disorders, migraine, and tinnitus. In recent years, the genetic predisposition for SCAD is also recognized as a predisposing factor. The precipitating factors are also different in women (emotional stress) compared with those in men (physical stress). Women experiencing SCAD frequently describe symptoms of anxiety and depression. These conditions could increase shear stress on the arterial wall and dissection of the coronary artery wall. Despite the advancement of SCAD, we can find significant differences in the clinical presentation between women and men.

Conclusion

When evaluating patients with chest pain or other ACS symptoms who have a low cardiovascular risk, particularly female patients, it is important to consider the possibility of ACS due to SCAD, particularly in conditions often associated with SCAD. This will increase the recognition of SCAD and the timely treatment of affected patients.

Pathophysiology of spontaneous coronary artery dissection: hematoma, not thrombus

Spontaneous coronary artery dissection (SCAD) accounts for 1.7%-4% of all acute coronary syndrome presentations, particularly among young women with an emerging awareness of its importance. The demarcation of acute SCAD from coronary atherothrombosis and the proper therapeutic approach still represents a major clinical challenge. Certain arteriopathies and triggers are related to SCAD, with high variability in their prevalence, and often, the cause remains unknown. The objective of this review is to provide contemporary knowledge of the pathophysiology of SCAD and possible therapeutic solutions.

Case Report on Spontaneous Coronary Artery Dissection: A Rare Culprit of Chest Pain

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic separation of the coronary artery wall with subsequent intramural hematoma (IMH) formation in the false lumen. It can be associated with or without an intimal tear. It is clinically divided into three types based on its angiographic appearance. Most SCAD cases are seen in young or middle-aged women, especially in a peripartum state. Additionally, SCAD patients usually have fewer cardiovascular risk factors and more commonly have predisposing conditions like fibromuscular dysplasia (FMD). Patients present with features of chest pain that radiates to the left arm or neck, shortness of breath (SOB), as well as nausea and vomiting. Coronary angiography is the most widely used first-line modality to diagnose this condition. Management is usually conservative; however, invasive procedures can be utilized for high-risk patients. We present a case of a 54-year-old woman with SCAD diagnosed using coronary angiography and treated conservatively with dual-antiplatelet therapy, culminating with resolution.

Pregnancy-Induced Hypertensive Disorder and Risks of Future Ischemic and Nonischemic Heart Failure

BACKGROUND

Although adverse pregnancy outcomes are associated with an increased risk of cardiovascular disease, studies on timing and subtypes of heart failure after a hypertensive pregnancy are lacking.

OBJECTIVES

The goal of this study was to assess the association between pregnancy-induced hypertensive disorder and risk of heart failure, according to ischemic and nonischemic subtypes, and the impact of disease characteristics and the timing of heart failure risks.

METHODS

This was a population-based matched cohort study, comprising all primiparous women without a history of cardiovascular disease included in the Swedish Medical Birth Register between 1988 and 2019. Women with pregnancy-induced hypertensive disorder were matched with women with normotensive pregnancies. Through linkage with health care registers, all women were followed up for incident heart failure, classified as ischemic or nonischemic.

RESULTS

In total, 79,334 women with pregnancy-induced hypertensive disorder were matched with 396,531 women with normotensive pregnancies. During a median follow-up of 13 years, rates of all heart failure subtypes were more common among women with pregnancy-induced hypertensive disorder. Compared with women with normotensive pregnancies, adjusted HRs (aHRs) with 95% CIs were as follows: heart failure overall, aHR: 1.70 (95% CI: 1.51-1.91); ischemic heart failure, aHR: 2.28 (95% CI: 1.74-2.98); and nonischemic heart failure, aHR: 1.60 (95% CI: 1.40-1.83). Disease characteristics indicating severe hypertensive disorder were associated with higher heart failure rates, and rates were highest within the first years after the hypertensive pregnancy but remained significantly increased thereafter.

CONCLUSIONS

Pregnancy-induced hypertensive disorder is associated with an increased short-term and long-term risk of incident ischemic and nonischemic heart failure. Disease characteristics indicating more severe forms of pregnancy-induced hypertensive disorder amplify the heart failure risks.

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.

Genetics of spontaneous cervical and coronary artery dissections

Objectives

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

Materials and methods

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

Results

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

Conclusions

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

Social Media and Cardiovascular Health: Implications for Women

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of mortality in adult women in the USA, yet CVD is underrecognized in women. Disparities in care are further pronounced in women of racial/ethnic minority backgrounds. In this review, we discuss the role of social media (SoMe) as a tool to (i) promote women's cardiovascular (CV) health and (ii) address and potentially reduce gaps in care, particularly in general cardiology (targeting atherosclerotic cardiovascular disease), cardio-oncology, and cardio-obstetrics. We also briefly discuss women's CV health as a common, although not unique, focus of women in cardiology on SoMe.

RECENT FINDINGS

Studies have suggested the utility of social media to help advance subspecialties of cardiology. Leaders within general cardiology, cardio-oncology, and cardio-obstetrics have curated social media strategies to advance their respective fields and call attention to cardiovascular health disparities in female populations and racial/ethnic minorities. In addition to these types of uses, women in cardiology also frequently use SoMe to encourage a career in cardiology and to share experiences, challenges, and resources for support and career advancement as healthcare professionals; men in cardiology and especially those who are allies for sex and racial/ethnic minorities also use SoMe for these means. Herein, we highlight the role and myriad applications of social media in the promotion of women's cardiovascular health. We discuss five primary roles of social media: increasing public awareness, disseminating medical literature in a rapid and accessible fashion, facilitating professional networking, serving as a platform for medical conferences, and empowering patients. These core strategies are discussed through the lens of general cardiology, cardio-oncology, and cardio-obstetrics. We also demonstrate how these applications can be leveraged to increase representation of women in cardiology, also supporting an increased focus on women's cardiovascular health.

Is location a significant parameter in the layer dependent dissection properties of the aorta?

Proper characterisation of biological tissue is key to understanding the effect of the biomechanical environment in the physiology and pathology of the cardiovascular system. Aortic dissection in particular is a prevalent and sometimes fatal disease that still lacks a complete comprehension of its progression. Its development and outcome, however, depend on the location in the vessel. Dissection properties of arteries are frequently studied via delamination tests, such as the T-peel test and the mixed-mode peel test. So far, a study that performs both tests throughout different locations of the aorta, as well as dissecting several interfaces, is missing. This makes it difficult to extract conclusions in terms of vessel heterogeneity, as a standardised experimental procedure cannot be assured for different studies in literature. Therefore, both dissection tests have been here performed on healthy porcine aortas, dissecting three interfaces of the vessels, i.e., the intima-media, the media-adventitia and the media within itself, considering different locations of the aorta, the ascending thoracic aorta (ATA), the descending thoracic aorta and the infrarenal abdominal aorta (IAA). Significant differences were found for both, layers and location. In particular, dissection forces in the ATA were the highest and the separation of the intima-media interface required significantly the lowest force. Moreover, dissection in the longitudinal direction of the vessel generally required more force than in the circumferential one. These results emphasise the need to characterise aortic tissue considering the specific location and dissected layer of the vessel.