Review on Spontaneous Coronary Artery Dissection

Hayes SN, Tweet MS, Adlam D, et al.
Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;76:961-984.

The following are key points to remember from this state-of-the-art review on spontaneous coronary artery dissection (SCAD):

  1. SCAD causes an acute coronary event related to compression of the true lumen of a coronary artery due to hematoma within the vessel wall. The majority may be related to an “outside-in” mechanism whereby the hematoma arises de novo in the media.
  2. The prevalence of SCAD has been estimated to be as high as 4% of patients presenting with acute coronary syndrome, and may account for 35% of acute coronary syndromes in women aged ≤50 years.
  3. Genetic evaluation for connective tissue disorders and aortopathy syndromes (i.e., Marfan, Loeys-Dietz, and Ehlers-Danlos) may be considered, although these account for only 5-9% of events. Additional genetic markers and associations are being investigated and referral for formal genetic evaluation can be considered.
  4. SCAD is vastly more common among women and is an important cause of pregnancy-associated myocardial infarction. However, it remains incompletely understood how sex hormones contribute to the risk of SCAD.
  5. The clinical presentation is similar to acute coronary syndromes of other causes, but the diagnosis may be missed because the patients are typically young or mid-life without cardiovascular risk factors. Two-thirds of patients recall extreme physical or emotional stress preceding the event. Pregnancy-associated SCAD is most common in the first week after delivery.
  6. Coronary angiography should be performed by an experienced interventional cardiologist. The left anterior descending artery is most commonly affected, and most cases of SCAD occur in the mid-distal arteries. Most SCAD appear as a long smooth narrowing (type 2), and a small proportion mimic atherosclerotic stenosis (type 3).
  7. Acute management: Thrombolytics should be avoided. Diagnostic coronary angiogram is recommended, but percutaneous coronary intervention is associated with higher complication rates and suboptimal outcomes, including risk of iatrogenic dissection or propagation of hematoma. If there is minimal ongoing ischemia with distal coronary involvement or preserved coronary flow, instrumentation is avoided because 95% of conservatively treated patients with SCAD will heal within 30 days.
  8. Early reinfarction can occur (6.1-17.5%) and longer length of stay may be preferred. Most recurrent chest pain is nonischemic.
  9. Medical management: Standard heart failure medications are indicated for left ventricular dysfunction, and hypertension should be treated. Statins are not indicated for treatment of SCAD.
  10. Post-SCAD chest pain is common and may persist for many months. Due to iatrogenic risk from invasive angiography, serial electrocardiography and biomarker assessment, and noninvasive cardiac computed tomography angiography should be considered. Nitrates may be effective, but are often limited by hypotension and migraines.
  11. Due to the association of SCAD with fibromuscular dysplasia, arterial imaging from head to pelvis to identify significant extracoronary vascular abnormalities is recommended.
  12. Recurrent SCAD has been reported in 10-30% of patients, but factors associated with recurrence remain poorly understood. Management of hypertension is recommended, and use of beta-blockers may be reasonable.
  13. Contraception should be discussed with patients. Effective options include subdermal levonorgestrel implants and the levonorgestrel-releasing intrauterine devices, which also reduce menstrual blood loss and are therefore beneficial for women with increased bleeding related to dual antiplatelet therapy.
  14. After SCAD, pregnancy is often discouraged, but women who strongly desire pregnancy should receive thorough preconception counseling.
  15. Future research areas include: the role of hormones, optimal diagnostic techniques, revascularization indications and techniques, use of antiplatelet and other pharmacologic agents, risk factors for recurrent SCAD and adverse outcomes, and the role of genetics.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, ACS and Cardiac Biomarkers, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension

Keywords: Acute Coronary Syndrome, Chest Pain, Coronary Angiography, Diagnostic Imaging, Dissection, Electrocardiography, Fibromuscular Dysplasia, Genetic Markers, Heart Failure, Hematoma, Hypertension, Levonorgestrel, Myocardial Infarction, Myocardial Ischemia, Nitrates, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Pregnancy, Vascular Diseases, Women

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