The etiology of spontaneous coronary dissection (SCAD) is not well defined and Non traditional risk factors (NT–RF) have assumed increasing interest, but few data are available. NT–RF include three categories: Sex–related (SR–NT–FR), Sex–predominant (SP–NT–RF) and Gender–related (GR–NT–RF). (Table 1) Aim of the Study The objective of our analysis was to evaluate the incidence of NT–RF in Parma SCAD registry population. Material and methods We reviewed 62 patients with SCAD enrolled between January 2013 through November 2021 Results Traditional risk factors were less common: hypertension was the most prevalent (39 pts, 62.9%). When considering NT–RF, 51 patients (82%) had at least one of all, with at least one SR–RF (66%) or GR–RF (64,5%). Patients with NT–RF were younger at time of SCAD (mean age 53 vs 66; p = 0.027) and they were predominantly females (48 vs 7 pts, p = 0.004) (Table 2). No differences were found among NT–RF SCAD and nNT–RF SCAD patients by fibromuscular dysplasia, peripheral arterial disease and chronic kidney disease. Patients with SCAD more often presented with non ST–segment elevation myocardial infarction (43 pts, 72.6%) vs ST–segment elevation (17 pts, 27.4%). No differences in clinical presentation and angiographic characteristics were found among NT–RF and nNT–RF patients group. MACE occurred in 17.7% of patients of the overall study population, at a median follow–up of 23 (interquartile range: 11;57) months. When comparing the incidence of cardiovascular events in the 2 study groups there was a trend toward a higher prevalence of MACE in NT–RF group without statistical significance (NT–RF SCAD 19.6% – nNT–RF SCAD 9.1%; p = 0.4). (Table 3) Conclusion SCAD is an emerging cause of myocardial infarction in young and middle–aged women without the traditional cardiovascular risk profile. Although overall survival seems good, SCAD is a potentially malignant disease which can present with ventricular arrhythmias and sudden cardiac death. Risk estimation is difficult in women, due to the scarce validity of prediction models, therefore a great effort must be made by the clinical community for the widespread diffusion and use of models incorporating NT–RF. Acknowledgement of peculiar features of this disease could help clinicians and researchers to establish targeted interventions for cardiovascular primary prevention, early diagnosis and secondary prevention in women, including rehabilitation and stress management programmes.
Background Cardiac arrest secondary to a spontaneous coronary artery dissection (SCAD) represents a challenging scenario. It deserves specific considerations due to the dramatic presentation and the need for secondary sudden cardiac death prevention. Methods We collected clinical data of four women admitted during the last two years in the Coronary Care Unit of Parma University Hospital, whose presentation of SCAD were cardiac arrest due to ventricular fibrillation (Table1). Results Three patients survived the acute phases. One patient, being considered at high risk of SCAD recurrence, received a subcutaneous implantable cardioverter–defibrillator (S–ICD). Acute management of cardiac arrest related to SCAD deserves specific considerations. Our case series illustrates the importance of prompt resuscitation manoeuvres and early defibrillation. We propose a flow chart of management of cardiac arrest in patient with suspect of SCAD (Figure 2 A). Evaluating risk of SCAD recurrence and sudden cardiac death. The management of SCAD patients complicated by malignant ventricular arrhythmias and cardiac arrest is challenging. Looking at published registries, it appears that SCAD patients are more likely to suffer from ventricular arrythmia or sudden cardiac death than non–SCAD MI patients. The risk–benefit ratio of ICD implantation in these patients remain uncertain . Evaluation of scar burden with CMR can help stratify the global arrhythmic risk, especially as extensive myocardial scar with a residual impaired LVEF increases the risk of future arrhythmic events (Figure 2 B). In our series, only one patient underwent S–ICD implantation, and the decision was mainly driven by the finding of underlying arteriopathy affecting other vascular territories, suggesting a potentially higher rate of SCAD recurrence. For this particular subset of patients, we propose an algorithm that combines predisposing factors and myocardial injury quantification data (Figure 2 B) that could be useful for the estimate of the risk of malignant arrythmias, as well as the risk of recurrence of SCAD, but needs to be validated in larger case studies. Conclusions The acute management of cardiac arrest related to SCAD deserves specific consideration. The residual myocardial damage, predisposing and precipitants factors should be evaluated in order to estimate the SCAD recurrence and sudden cardiac death risks.
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