Spontaneous Coronary Artery Dissection

Abstract

Background-Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is underdiagnosed and an important cause of myocardial infarction in young women. The frequency of predisposing and precipitating conditions and cardiovascular outcomes remains poorly described. Methods and Results-Patients with NA-SCAD prospectively evaluated (retrospectively or prospectively identified) at Vancouver General Hospital were included. Angiographic SCAD diagnosis was confirmed by 2 experienced interventional cardiologists and categorized as type 1 (multiple lumen), 2 (diffuse stenosis), or 3 (mimic atherosclerosis). Fibromuscular dysplasia screening of renal, iliac, and cerebrovascular arteries were performed with angiography or computed tomographic angiography/MR angiography. Baseline, predisposing and precipitating conditions, angiographic, revascularization, inhospital, and long-term events were recorded. We prospectively evaluated 168 patients with NA-SCAD. Average age was 52.1±9.2 years, 92.3% were women (62.3% postmenopausal). All presented with myocardial infarction. ECG showed ST-segment elevation in 26.1%, and 3.6% had ventricular tachycardia/ventricular fibrillation arrest. Fibromuscular dysplasia was diagnosed in 72.0%. Precipitating emotional or physical stress was reported in 56.5%. Majority had type 2 angiographic SCAD (67.0%), only 29.1% had type 1, and 3.9% had type 3. The majority (134/168) were initially treated conservatively. Overall, 6 of 168 patients had coronary artery bypass surgery and 33 of 168 had percutaneous coronary intervention in-hospital. Of those treated conservatively (n=134), 3 required revascularization for SCAD extension, and all 79 who had repeat angiogram ≥26 days later had spontaneous healing. Two-year major adverse cardiac events were 16.9% (retrospectively identified group) and 10.4% (prospectively identified group). Recurrent SCAD occurred in 13.1%. Conclusions-Majority of patients with NA-SCAD had fibromuscular dysplasia and type 2 angiographic SCAD. Conservative therapy was associated with spontaneous healing. NA-SCAD survivors are at risk for recurrent cardiovascular events, including recurrent SCAD. (Circ Cardiovasc Interv. 2014;7:645-655.)

A case of spontaneous coronary artery dissection presenting with acute anterior wall myocardial infarction in a young adult male – an increasingly recognized rare disease

“…Long-term complications post-discharge, however, were significantly higher. Recurrence of SCAD was reported in approximately 15% at 2-year follow up [7]. Subacute MACEs were reported in up to 20% during the same follow-up period.…”

“…Subacute MACEs were reported in up to 20% during the same follow-up period. The rate of MACEs increases proportionally with time, reported to be in 50% at 10-year follow-up period [7,8,14]. The high long-term MACEs rates emphasize the importance of close follow up of SCAD patients with a specialized cardiovascular specialist.…”

How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

“…Every coronary segment may be potentially involved but Virmani et al documented a significantly higher involvement of left anterior descendent (70% to 75% of cases) followed by the right coronary artery (20% of cases); a remarkable predilection for distal and smaller tracts has been also described [42][43][44]. A gender difference has moreover been reported with left anterior descendent more frequently involved in females, while right coronary artery in males [45,46] (Figure 2).…”

“…In general, the first-line approach consists of a conservative medical therapy [1]. This widespread opinion depends on the evidence that angiographic healing occurs in the majority of cases, varying from 73% to 90% and reaching 100% if the control angiography is performed 26 days after SCAD onset [42,58]. Figure 3a).…”

“…In a prospective observational study, Saw described a 64% procedural success rate for PCI; among the patients facing unsuccessful PCI 57% had extension of SCAD, 6% definite stent thrombosis, and 12% underwent urgent CABG [42].…”