Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

Abstract

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): It's Time to Face Reality!

“…Studies of intracoronary imaging have shown that ≈40% of patients with MINOCA have some evidence of plaque disruption 16, 17. Although intravascular ultrasound is helpful in demonstrating plaque rupture,16 Optical coherence tomography is a better tool for identifying patients with plaque erosion18 and may be superior for the assessment of patients with spontaneous coronary artery dissection 19. In the current report, intracoronary imaging was not routinely utilized, and that may explain why a large number of patients with MINOCA were “undefined.” Thrombophilia disorders can be detected in up to 14% of MINOCA patients4; however, a hypercoagulability syndrome was detected in only 3% of MINOCA patients in the current report, casting doubt on whether extensive thrombophilia testing was really undertaken in VIRGO.…”

Spontaneous coronary artery dissection in a man with intense coughing spasms

“…The left circumflex, ramus and obtuse marginal branches are involved in 15%–45% of cases, while the RCA and acute marginal, posterior descending, and posterolateral branches are involved in 10%–39% of cases. The left main artery is the culprit in up to 4% of cases 6. In our patient, the anterior branch of the second obtuse marginal artery was involved.…”

“…Due to the recent heightened awareness of SCAD among healthcare providers and affected patients, use of invasive angiography and advanced intravascular diagnostic imaging techniques, it is suggested that the incidence of SCAD may be higher than previously thought, especially in young women 6. In men, less than 30% of cases have been reported,4 with the principal precipitant in men identified as extreme physical activity 8…”

“…One limitation of this imaging method is its inability to depict the arterial wall, given that it provides two-dimensional images 6. Intravascular ultrasound and optical coherence tomography (OCT) are intracoronary imaging modalities which provide detailed visualisation of the arterial wall, useful in the confirmation of the presence of SCAD 6 18.…”

A 42-year-old woman with acute myocardial infarction

“…SCAD typically occurs in younger, mainly female patients compared with atherothrombotic coronary syndromes 1–3. Intravascular ultrasound or coronary optical coherence tomography can confirm SCAD by demonstration of intramural haematoma,1 but neither was performed in this case.…”