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Clinical features, management, and prognosis of spontaneous coronary artery dissection
Marysia S Tweet1, Sharonne N Hayes, Sridevi R Pitta
1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
Insights
Spontaneous coronary artery dissection (SCAD) primarily affects young women and often presents as a heart attack. Long-term risks include recurrence and major adverse cardiac events, highlighting the need for ongoing patient monitoring.
Area of Science:
- Cardiology
- Vascular Medicine
- Public Health
Background:
- Spontaneous coronary artery dissection (SCAD) is an acute coronary syndrome with unclear etiology.
- Clinical presentation and long-term prognosis of SCAD require further characterization.
Purpose of the Study:
- To evaluate the incidence, clinical features, and outcomes of SCAD.
- To assess in-hospital and long-term risks associated with SCAD.
- To investigate potential contributing factors and associated conditions like fibromuscular dysplasia.
Main Methods:
- Retrospective single-center cohort study of 87 patients with angiographically confirmed SCAD.
- Evaluation of patient demographics, clinical presentation, treatment strategies, and in-hospital events.
- Long-term follow-up for SCAD recurrence and major adverse cardiac events (MACE).
Main Results:
- SCAD predominantly affects young individuals (mean age 42.6 years), with 82% being female.
- Extreme exertion was a more common trigger in men, while postpartum status was noted in 18% of women.
- ST-elevation myocardial infarction was the presentation in 49% of cases; multivessel SCAD occurred in 23%.
- Conservative management and coronary artery bypass grafting had uncomplicated in-hospital courses.
- Percutaneous coronary intervention (PCI) was associated with 35% technical failure and one death.
- SCAD recurrence occurred in 15 female patients during a median follow-up of 47 months.
- The estimated 10-year MACE rate was 47%.
- Fibromuscular dysplasia was incidentally found in 50% of iliac artery angiograms and in two patients with carotid dissection.
Conclusions:
- SCAD impacts a young, predominantly female demographic, often presenting as ST-elevation myocardial infarction.
- While in-hospital mortality is low, PCI carries significant complication risks.
- The high rates of SCAD recurrence and long-term MACE necessitate close patient follow-up.
- Fibromuscular dysplasia represents a novel association and potential causative factor in SCAD.
Background:
Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized.
Methods And Results:
A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection.
Conclusions:
SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.
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