Spontaneous Coronary Artery Dissection: One Disease, Variable Presentations, and Different Management Approaches

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. It occurs predominantly among younger females, typically in the absence of atherosclerotic coronary artery disease. Presentations vary greatly and this condition can be fatal. Given its rarity, there are no management guidelines. We present six patients with SCAD with different presentations and treatment approaches as examples in our literature review. Two patients presented with ST elevation myocardial infarction (STEMI), two with non-STEMI (NSTEMI), and two with cardiac arrest. Patients were treated according to the presentation, clinical stability, and extension and distribution of the dissection. Four patients underwent emergent percutaneous coronary intervention (PCI) and one was clinically stable and treated medically initially and underwent an elective PCI after 4 weeks when coronary angiogram showed persistent dissection. Another patient was treated medically as he was hemodynamically stable and the dissection affected a small branch. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used for diagnosis confirmation as well as during and after PCI to assure good stent apposition. All patients had excellent outcome. SCAD is a rare cause of acute coronary syndrome and a high index of suspicion is crucial for early diagnosis. In patients with early presentation, limited disease, and ongoing symptoms, emergent cardiac catheterization with PCI has excellent outcome. However, in stable patients, medical management and elective PCI in few weeks if the dissection persists is a more reasonable approach. IVUS and OCT are invaluable especially in ambiguous cases.

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient‐Informed Investigation

“…Participants in this study, the majority women, reported diverse symptoms of SCAD that varied in duration and intensity. Symptoms reported did not differ from those reported in extant literature on SCAD, 40 with chest pain as the chief symptom. 41 Other cardiac symptoms reported (eg, jaw pain, nausea, dizziness) are also consistent with the broader literature in women presenting with myocardial infarction.…”

Spontaneous Coronary Artery Dissection in a Young Man

“…The discordance between clinical presentation and angiographic finding posed a unique challenge in therapeutic decision making. Unlike traumatic dissection of coronary arteries, more than half of SCAD heals spontaneously over time [ 2 , 7 ]. Due to this substantial rate of spontaneous healing, conservative medical management is recommended for patients who are hemodynamically stable with a minor dissection.…”

“…The median time for SCAD recurrence is 2.8 years with an interval of 3 days to 12 years [ 9 ]. Hypertension and the use of calcium channel blockers are notable risk factors for SCAD recurrence [ 2 , 9 ]. Reported protective factor against SCAD recurrence was beta-blocker therapy [ 4 , 9 ].…”

“…This intramural hematoma, in turn, leads to compression and occlusion of the arterial lumen [ 1 ]. SCAD has a broad spectrum of clinical presentation, ranging from asymptomatic state to myocardial infarction, cardiogenic shock, and sudden cardiac death [ 2 ]. It is estimated that approximately 1.7-4% of acute coronary syndrome (ACS) is attributed to SCAD.…”

Spontaneous coronary dissection and asymptomatic splenic artery aneurysms in a young woman

“…Importantly, not properly diagnosed and treated it could lead to serious clinical consequences, including cardiac arrest and death. It is based on intimal tear or intramural bleeding of the vasa vasorum leading to the creation of a false lumen and to myocardial ischemia [ 2 ]. More frequently, it appears in young or middle-aged women [ 3 ].…”