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Spontaneous coronary artery dissection: new insights into diagnosis and treatment
Fernando Alfonso1, Teresa Bastante, Marcos García-Guimaraes
1aDepartment of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain bDivision of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA cDivision of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada.
Insights
Spontaneous coronary artery dissection (SCAD) is a challenging condition often affecting middle-aged individuals with risk factors. While many patients stabilize with conservative management, recurrences can occur, necessitating careful follow-up.
Area of Science:
- Cardiology
- Vascular Biology
- Medical Diagnostics
Background:
- Spontaneous coronary artery dissection (SCAD) is an uncommon yet significant cause of acute coronary syndrome, particularly in women, with an often-elusive etiology.
- Historically, understanding of SCAD pathophysiology was limited; recent prospective studies have significantly advanced knowledge, revealing a broader patient demographic and associated conditions like fibromuscular dysplasia.
- SCAD diagnosis has surged due to increased awareness and advanced imaging, aiding in identifying cases previously misdiagnosed.
Purpose of the Study:
- To provide a comprehensive and contemporary review of spontaneous coronary artery dissection (SCAD).
- To update knowledge on SCAD's pathophysiology, clinical presentation, diagnostic methods, and management strategies.
- To highlight recent advancements in understanding and treating this complex cardiovascular condition.
Main Methods:
- Review of contemporary literature and prospective patient series on spontaneous coronary artery dissection (SCAD).
- Analysis of diagnostic insights from high-resolution intracoronary imaging techniques.
- Evaluation of clinical outcomes and management approaches, including conservative strategies and revascularization.
Main Results:
- SCAD typically presents as acute coronary syndrome, often in middle-aged individuals with risk factors, contrary to the initial perception of it affecting only young women.
- The condition can manifest with intimal tears and dual lumens or as intramural hematomas, with fibromuscular dysplasia being a key associated condition.
- Most SCAD patients stabilize with conservative management and show spontaneous healing, but recurrence rates range from 10-20%, and revascularization poses significant challenges.
Conclusions:
- Spontaneous coronary artery dissection (SCAD) requires heightened clinical suspicion and advanced diagnostic tools for accurate identification.
- A conservative, watchful waiting approach is generally recommended initially for SCAD, with revascularization reserved for specific cases of refractory ischemia.
- Despite challenges, ongoing research into novel interventions offers promise for improving outcomes in SCAD patients.
Abstract:
Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.
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