Spontaneous Coronary Artery Dissection: Latest Developments and New Frontiers

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized entity leading to myocardial infarction especially in women. Multiple observational studies have been published in the recent years. This review summarizes the current body of knowledge and recent developments in SCAD epidemiology, presentation, diagnosis, and management.

Contemporary series have estimated the incidence of SCAD to be up to ~ 4% of all patients presenting with acute coronary syndrome (ACS). Fibromuscular dysplasia, hormonal therapy, multiparity, connective tissue disorders, and systemic inflammatory diseases have been identified as predisposing factors for SCAD. Although SCAD typically presents as ACS, emerging evidence shows that cardiogenic shock, ventricular arrhythmia, and cardiac arrest are not uncommon, with higher incidence of complication among peripartum women. Advances in SCAD diagnosis include a novel angiographic classification of SCAD and the use of optical coherence tomography and intravascular ultrasound to aid in diagnosis. Management depends on clinical stability and the presence of high-risk features. Beta-blockers are the mainstay of medical therapy long term and was shown to reduce recurrent SCAD. The largest study to date including 750 patients across 22 North American centers showed that the majority of patients was managed conservatively and that the technical success rates of percutaneous coronary intervention were low. Following discharge, SCAD-specific cardiac rehabilitation had been shown to have long-term cardiovascular benefits. The recent years have seen a surge in SCAD awareness and publication. Centralized patient networks as well as core lab interpretation of diagnostic data have contributed significantly to the growing body of knowledge. Current efforts to delineate the pathogenesis of SCAD; improve medical and revascularization therapy; and understand complications such as cardiogenic shock and cardiac arrest will serve as foundational building blocks for future research and innovation.