ReviewSpontaneous Coronary Artery Dissection
Section snippets
Definition and Epidemiology
SCAD is defined as a nontraumatic and noniatrogenic separation of the coronary arterial wall by intramural hemorrhage creating a false lumen, with or without an intimal tear. The separation can occur between the intima and media, or between the media and adventitia. The resulting intramural hematoma (IMH) compresses the arterial lumen, compromising antegrade blood flow to varying degrees, and subsequent myocardial ischemia or infarction.
SCAD is considered a rare cause of acute coronary
Pathogenesis and Pathophysiology
There are 2 proposed mechanisms of SCAD: (1) initiation of a medial dissection and hemorrhage by an intimal tear and creation of a false lumen; and (2) an intramedial hemorrhage without an intimal tear causing a medial dissection, perhaps caused by rupture of the vaso vasorum (Fig. 1).12 The first mechanism might appear angiographically as multiple radiolucent lumens, typically with slow clearing or hang-up of contrast, and rarely have an intimal tear appearance. The second mechanism might
Diagnosis of SCAD
Despite the limitations of angiography, it remains an indispensable diagnostic test for SCAD and should be done promptly in suspected cases. Coronary angiography is a 2-dimensional luminogram, and often inadequate to differentiate atherosclerotic from nonatherosclerotic forms of luminal obstruction. For patients with an intimal tear, SCAD might appear as multiple radiolucent lines separating true and false lumens, with or without slow contrast clearing (Fig. 2). However, patients with IMH
Management of SCAD
Early diagnosis is crucial for managing SCAD patients, because it might preempt the use of unnecessary and potentially harmful pharmacologic therapies. Unfortunately, unlike in the case of atherosclerotic coronary artery disease (CAD), there are no prospective randomized data that specifically address the management of SCAD.
Long-term Prognosis of SCAD
The prognosis of patients with SCAD has not been well studied, with limited case reports and small retrospective case series published. Older reports had suggested high mortality risks with SCAD, with cases often reported as autopsies. However, recent retrospective series show that most patients survive their initial SCAD hospitalization, with low in-hospital mortality ranging from 0 to 4%.6, 9, 10, 11 This variability in acute SCAD outcome is likely a combination of heterogeneity of the
Summary
SCAD remains an infrequent condition that is underdiagnosed among patients presenting with ACS. There is a predilection for young women without traditional cardiovascular risk factors, and SCAD is increasingly diagnosed in women who are not peripartum. We discovered a strong association between SCAD and FMD, where approximately 90% of women with SCAD have noncoronary FMD. We suspect that these seemingly healthy patients have underlying coronary FMD that predisposed them to SCAD. The long-term
Disclosures
The author has no conflicts of interest to disclose.
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See editorial by Mintz, pages 1017-1020 of this issue.
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