From the Guidelines
Spontaneous Coronary Artery Dissection (SCAD) typically presents with elevation of cardiac biomarkers associated with chest discomfort, and it is essential to recognize that SCAD accounts for up to 4% of all acute coronary syndromes (ACS), with a higher incidence in women <60 years of age and those with a history of fibromuscular dysplasia, anxiety, depression, or previous neuropsychiatric disorders 1. The clinical presentation of SCAD can vary considerably, but the most common presentation is elevation of cardiac biomarkers associated with chest discomfort. Key aspects of SCAD include:
- A non-atherosclerotic, non-traumatic, or iatrogenic separation of the coronary arterial tunics secondary to vasa vasorum hemorrhage or intimal tear, which creates a false lumen, coronary compression, and downstream myocardial ischemia 1.
- SCAD primarily affects women, particularly those without traditional cardiovascular risk factors, often during peripartum periods or in those with fibromuscular dysplasia.
- The incidence of SCAD is reported to be much higher (22-35% of ACS) in women <60 years of age, in pregnancy-related MI, and in patients with a history of fibromuscular dysplasia, anxiety, depression, or previous neuropsychiatric disorders 1. The optimal management of SCAD is still unclear, but a conservative approach should be the preferred strategy, with the exception of very high-risk profile patients, and the decision to treat either with a conservative medical approach or to perform PCI or CABG surgery must be individualized and based on both clinical and angiographic factors 1. Some essential considerations for managing SCAD include:
- Aggressive anti-hypertensive therapy to ensure optimal blood pressure control, as hypertension is an independent predictor of recurrent SCAD 1.
- Beta-blockers, which have been reported to be significantly associated with a reduced risk of recurrent SCAD, should be considered 1.
From the Research
Presentation of Spontaneous Coronary Artery Dissection (SCAD)
The presentation of SCAD can vary, with patients experiencing a range of clinical scenarios, including:
- Angina pectoris
- Cardiogenic shock
- Sudden cardiac death
- Acute myocardial infarction
- ST-elevation myocardial infarction (STEMI) 2, 3, 4
- Acute coronary syndrome (ACS) 5, 6, 3
Clinical Manifestation
The clinical manifestation of SCAD can be influenced by various factors, such as:
- Location and extent of dissection
- Amount of ischemic myocardium at risk
- Presence of high-risk features, such as left main or multivessel involvement, hemodynamic instability, recurrent chest pain, or ST elevation 3
- Presence of extracardiac arthropathies or connective tissue diseases 3
Diagnostic Challenges
SCAD can be underdiagnosed or misdiagnosed due to its rare occurrence and atypical presentation, particularly in young patients without atherosclerotic risk factors 6, 3, 4 The diagnosis of SCAD is typically made by coronary angiography, aided by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) 2, 6, 3, 4