Is there an association between hypercoagulable (coagulation disorder) states and spontaneous coronary artery dissection (SCAD)?

From the Guidelines

There is a potential link between hypercoagulable states and spontaneous coronary artery dissection (SCAD), as suggested by the most recent study in 2023 1. Hypercoagulable conditions may contribute to SCAD by increasing the risk of thrombus formation at the site of arterial wall tears, potentially worsening outcomes. Specific hypercoagulable conditions that have been associated with SCAD in case reports include Factor V Leiden mutation, protein C and S deficiencies, antiphospholipid syndrome, and elevated homocysteine levels. The pathophysiological mechanism likely involves the hypercoagulable state creating additional stress on already compromised arterial walls or exacerbating the consequences of an initial dissection. For patients with both conditions, management typically includes antiplatelet therapy (aspirin 81-325mg daily) rather than full anticoagulation, unless specifically indicated for other reasons, as noted in the 2018 American Heart Association statement 1. Anticoagulation in SCAD carries theoretical risks of extending the dissection or increasing bleeding into the arterial wall. Clinicians should consider screening for hypercoagulable disorders in SCAD patients with personal or family histories of thrombotic events, recurrent SCAD, or SCAD occurring in unusual demographic groups, as recommended by the 2020 ESC guidelines 1. The relationship works both ways - patients with known hypercoagulable states who present with chest pain should be evaluated with consideration for SCAD, especially if they lack traditional atherosclerotic risk factors. Some key points to consider in the management of SCAD include:

• The optimal management of SCAD is still unclear, and a conservative approach should be the preferred strategy, unless the patient has ongoing ischemia or high-risk anatomy, as noted in the 2020 ESC guidelines 1.
• Revascularization by PCI or CABG should be considered on a case-by-case basis, taking into account the patient's clinical and angiographic factors, as discussed in the 2018 case-based implementation of the ESC focused update on dual antiplatelet therapy in coronary artery disease 1.
• The use of intravascular imaging with ultrasound or OCT can be helpful in confirming the diagnosis of coronary dissection and documenting the extension of the disease, but should be considered only if the decision to proceed to revascularization has already been made, as noted in the 2018 case-based implementation of the ESC focused update on dual antiplatelet therapy in coronary artery disease 1. Key considerations for patients with SCAD include:
• The importance of aggressive anti-hypertensive therapy to ensure optimal blood pressure control, as recommended by the 2020 ESC guidelines 1.
• The potential benefits of beta-blockers in reducing the risk of recurrent SCAD, as noted in the 2020 ESC guidelines 1.
• The need for careful evaluation and management of patients with SCAD, taking into account their individual clinical and angiographic factors, as discussed in the 2018 case-based implementation of the ESC focused update on dual antiplatelet therapy in coronary artery disease 1.

From the Research

Association between Hypercoagulable States and Spontaneous Coronary Artery Dissection (SCAD)

• There is evidence to suggest that hypercoagulable states, such as antiphospholipid syndrome (APS), may be associated with an increased risk of SCAD 2.
• A case report described a patient with SCAD who was also diagnosed with APS and leukemia, highlighting the potential link between hypercoagulable states and SCAD 2.
• However, the current understanding of the pathophysiology and management of SCAD is limited, and more research is needed to fully understand the relationship between hypercoagulable states and SCAD 3, 4, 5, 6.
• Other studies have identified predisposing factors for SCAD, including fibromuscular dysplasia, inherited connective tissue disorders, and systemic inflammatory diseases, but the role of hypercoagulable states in SCAD is not yet fully understood 4, 5, 6.

Predisposing Factors for SCAD

• Fibromuscular dysplasia is a common predisposing factor for SCAD, and has been identified in up to 72% of patients with SCAD 4.
• Other predisposing factors for SCAD include inherited connective tissue disorders, systemic inflammatory diseases, pregnancy, and the use of sex hormones or steroids 6.
• The relationship between SCAD and other systemic vasculopathies, such as fibromuscular dysplasia, is an area of ongoing research 5.

Clinical Presentation of SCAD

• SCAD can present with a range of symptoms, including chest pain and acute myocardial infarction, and can be difficult to diagnose 4, 6.
• The clinical presentation of SCAD can vary between women and men, with women more likely to experience emotional stress as a precipitating factor 6.
• The diagnosis of SCAD requires a high index of suspicion, particularly in patients with a low cardiovascular risk profile 6.