Spontaneous coronary artery dissection with cardiogenic shock: How frequent is it? How should we treat it?

Abstract

Key Points Spontaneous Coronary Artery Dissection (SCAD) may represent 1–2% of all STEMI and 20–25% of STEMI in women <50. Cardiogenic shock is relatively low (2–3%) in the overall SCAD population but may occur in up to 25% of SCAD patients with STEMI. The ideal treatment for a SCAD patient with cardiogenic shock requires thoughtful patient specific‐management decisions in regards to both the choice of revascularization and the choice of mechanical circulatory support. When treated appropriately these patients have excellent long‐term outcome, with mortality lower than STEMI or cardiogenic shock related to atherosclerosis.

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection

“…Data regarding the use of MCS and outcomes is limited amongst patients with SCAD and CS and is based on isolated case reports and small case series 9,21 . In our study, the use of MCS, including IABP, p‐LVAD, and ECMO, is higher among SCAD patients as compared to patients with atherosclerosis.…”

“…SCAD is an increasingly recognized cause of myocardial infarction in women, with a wide spectrum of clinical presentations ranging from acute coronary syndrome to ventricular arrhythmias, CS, and sudden cardiac death. 1,[7][8][9] The true incidence of CS among patients with SCAD is difficult to discern as most current literature comes from single-center studies and retrospective registries; nonetheless, with increasing frequency of coronary angiography, intra-coronary imaging, and increasing awareness of this condition, SCAD is increasingly diagnosed. Most SCAD patients are managed conservatively due to the risk of iatrogenic propagation of dissections and/or propagation of intramural hematomas with coronary instrumentation.…”

“…There is a lack of data on the true incidence of CS in SCAD, with some registries reporting a prevalence of 2%-3%, with the majority of CS occurring in patients presenting with STEMI or in peripartum patients. 9 Previous studies looking at the incidence and prevalence of CS in the United States have not reported the numbers among patients with SCAD. 15 We report that CS complicates 9% of all patients with AMI due to SCAD, as compared to 5% among patients with AMI without SCAD.…”

“…Women account for almost 90% of SCAD cases, which is an increasingly recognized mechanism accounting for approximately 25% of AMI presentations in women under 50 years 2–6 . Though SCAD commonly presents with chest pain, elevated cardiac biomarkers, and electrocardiographic findings of ST‐segment elevation or non‐ST segment elevation AMI (STEMI and non‐STEMI), SCAD has a broad spectrum of clinical presentations, which includes ventricular arrhythmias, cardiogenic shock (CS), and sudden cardiac death 1,7–9 . Despite its occurrence in clinical practice, the incidence and outcomes of CS complicating SCAD are largely unknown.…”

“…[2][3][4][5][6] Though SCAD commonly presents with chest pain, elevated cardiac biomarkers, and electrocardiographic findings of ST-segment elevation or non-ST segment elevation AMI (STEMI and non-STEMI), SCAD has a broad spectrum of clinical presentations, which includes ventricular arrhythmias, cardiogenic shock (CS), and sudden cardiac death. 1,[7][8][9] Despite its occurrence in clinical practice, the incidence and outcomes of CS complicating SCAD are largely unknown. Therefore, we aimed to identify the incidence, predictors, and outcomes of CS among women presenting with AMI due to SCAD (AMI-SCAD) compared to women presenting with AMI due to other causes (AMI-nonSCAD) utilizing a large nationally representative sample of United States hospital admissions.…”