Spontaneous Coronary Artery Dissection (SCAD): New Insights into This Not-So-Rare Condition

Abstract

Spontaneous coronary artery dissection (SCAD) is an uncommon and poorly understood cause of acute coronary syndrome (ACS), myocardial infarction, and sudden cardiac death.1 Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall that creates an intimal flap or intramural hematoma, obstructing blood flow (Fig. 1A) The true prevalence, causes, prognosis, recurrence rate, and optimal management of SCAD remain uncertain, but recent increases in the use of social media, in patient engagement, and in the formation of disease-specific online communities have facilitated case finding and have accelerated the progress of SCAD research.2 Advances in imaging techniques and better recognition of acute SCAD have led to several new insights and have generated interest in this underrecognized and understudied condition.The demographics, causes, and natural history of ACS associated with SCAD are distinct from those of ACS caused by atherosclerosis or plaque rupture. Spontaneous coronary artery dissection patients are typically young women who do not have risk factors for atherosclerosis. The average age of incident SCAD is 42 years, with reported cases from the age of 14 years to well into the 7th decade. Approximately 80% of SCAD patients are female and, of those, 20% to 25% of cases occur in the peripartum period.In recent accounts of series that have used careful angiographic evaluation or advanced intracoronary imaging to detect intramural hematoma and more subtle dissections, the true prevalence of SCAD (a phenomenon once believed rare) has been reported to be as high as 1% to 4% of ACS overall.3 Moreover, SCAD has been found to be a factor in up to 40% of heart attacks in women under the age of 50 years.4 About half of SCADs initially present as ST-segment-elevation myocardial infarction, and one quarter present with multivessel involvement. 1 Diagnosis and ManagementThe diagnosis of SCAD requires careful angiographic study and a high degree of suspicion. Accurate differentiation of ACS due to SCAD from ACS due to atherosclerosis is crucial, because the approaches to both acute and long-term management are different. Intravascular ultrasonography and optical coherence tomography can be invaluable adjuncts to inadequate or nondiagnostic angiographic imaging. Advanced imaging in the acute setting should be strongly considered in individuals who do not have standard coronary heart disease risk factors, in young or postpartum women, or in patients who show an absence of plaque in noninfarct-related coronary arteries.The most important reasons for accurately diagnosing SCAD are that patients undergoing percutaneous coronary intervention (PCI) for acute SCAD have technical success rates that are markedly reduced (Fig. 1B) compared with PCI success rates for atherosclerotic ACS (62% vs 92%) 1,5 ; and the substantial rate of spontaneous vascular healing 1,6 suggests a role for conservative management in stable SCAD patients who have preserved coronary flow.5 Although conservativ...

What Clinicians Should Know Αbout Spontaneous Coronary Artery Dissection

“…24 Patients with SCAD are often young women frequently perceived as otherwise fit. However, CR is encouraged for both emotional and physical health advantages 15 and considered both beneficial and safe among patients with SCAD. 25 In a cross-sectional study of 158 SCAD survivors, depression and anxiety symptoms were common, especially among young and peripartum women.…”

“…1,[11][12][13] Accordingly, short-term and long-term management strategies also differ substantially. 14,15 SCAD PRESENTATION AND DIAGNOSIS SCAD presents primarily as noneST-elevation MI and ST-elevation MI. SCAD can also present as unstable angina or sudden cardiac death.…”

Spontaneous triple-vessel coronary artery dissection in a patient with Ehlers-Danlos Type IV

“…Average age for the presentation of SCAD is 42 years, though there have been cases reported from the first decade to the seventh decade of life. Approximately 80% of SCAD patients are female and, of those 20% to 25% of cases occur in the peri-partum period [5][6][7].…”

Sudden cardiac death due to coronary artery dissection as a complication of cardiac sarcoidosis

“…Of particular note is that this is a case of a postpartum female [1]. Nonsarcoid SCAD accounts for 0.1-4% of acute coronary syndromes (ACSs) and has a multifactorial etiology most typically involving an arteriopathy [2]. Examples of arteriopathies that can lead to SCAD include atherosclerosis, the peripartum state, connective tissue disorders, systemic inflammatory conditions and coronary artery spasm [3].…”