Spontaneous coronary artery dissection

Abstract

Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection

“…These findings are at variance with previous reports of spontaneous healing in most nonpregnant patients with SCAD 103,117,127,128 and emphasize the difference in the natural history of this disease when associated with pregnancy.…”

A case of pregnancy-associated acute myocardial infarction with refractory ventricular fibrillation and heart failure

“…Tweet et al reported an annual incidence of SCAD of 0.26 per 100,000 persons [6]. However, the true incidence of SCAD may be underestimated for three reasons: (1) initial presentation as sudden death, (2) underuse or avoidance of coronary angiography in young women, and (3) under-recognition of angiographic characteristics of the disease [4,6].…”

“…Angiographically or on autopsy, SCAD was reported in 27-43% of patients, whereas atherosclerotic plaque was observed in 27-40% [3,5]. SCAD is a rare condition with a prevalence of 0.1-1.1% on angiography [4]. Tweet et al reported an annual incidence of SCAD of 0.26 per 100,000 persons [6].…”

“…The primary cause of PAMI is spontaneous coronary dissection (SCAD), which continues to present substantial management difficulties [3,4]. There are no guidelines for optimal treatment of this challenging condition.…”

Spontaneous coronary artery dissection treated with biovascular scaffolds: Old riddle, novel approach

“…Spontaneous coronary artery dissection (SCAD) is a rare, poorly understood disease (incidence 0.1-1.1%) [1]. Some large studies have been done to give more clarity on this disease, hence some controversy exists as to previous generally accepted ideas.…”