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Spontaneous coronary artery dissection: review, case report and analysis of COVID-19-related cases
Joseph Cosma1, Alessandro Russo2, Valentina Ferradini3
1Cardiovascular Institute of Caen, Saint Martin Private Hospital, Caen, France - josephcosma1990@gmail.com.
Insights
Spontaneous coronary artery dissection (SCAD) is a debated cause of acute coronary syndromes, often affecting women. This review explores SCAD pathophysiology, diagnosis, and treatment, including cases linked to COVID-19.
Area of Science:
- Cardiology
- Vascular Biology
Background:
- Spontaneous coronary artery dissection (SCAD) represents 1-4% of acute coronary syndromes (ACS).
- Pathophysiology and optimal management of SCAD remain subjects of ongoing research and debate.
- SCAD predominantly affects middle-aged women, often without traditional cardiovascular risk factors.
Purpose of the Study:
- To provide a comprehensive literature review on spontaneous coronary artery dissection (SCAD).
- To discuss the proposed pathophysiological mechanisms, including the "inside-out" and "outside-in" hypotheses.
- To examine the role of predisposing and precipitating factors, diagnostic modalities, and current treatment strategies for SCAD.
Main Methods:
- Literature review of spontaneous coronary artery dissection (SCAD).
- Analysis of diagnostic criteria, with coronary angiography as the gold standard.
- Review of current treatment recommendations, distinguishing between stable and unstable patients.
Main Results:
- SCAD pathophysiology is hypothesized to involve either intimal tears or vasa vasorum hemorrhage.
- Etiology is multifactorial, with various predisposing and precipitating factors identified.
- Eleven cases of SCAD in COVID-19 patients suggest a link involving systemic and vascular inflammation.
Conclusions:
- A conservative management approach is generally favored for hemodynamically stable SCAD patients.
- Urgent revascularization may be necessary for hemodynamically unstable SCAD patients.
- COVID-19 may be an emerging trigger for SCAD, likely due to inflammatory responses.
Abstract:
Spontaneous coronary artery dissection (SCAD) accounts for 1-4% of all acute coronary syndromes (ACS). Since the first description in 1931, our understanding of the disease has evolved; however, its pathophysiology and management are still a matter of debate. SCAD typically occurs in a middle-aged woman with no or few traditional cardiovascular risk factors. Two hypotheses have been proposed to explain the pathophysiology depending on the primary event: an intimal tear in the "inside-out" hypothesis and a spontaneous hemorrhage from the vasa vasorum in the "outside-in" hypothesis. Etiology appears to be multifactorial: different predisposing and precipitating factors have been identified. Coronary angiography is the gold standard for the diagnosis of SCAD. Current recommendations on the treatment of SCAD patients are based on expert opinions: a conservative strategy is preferred in hemodynamically stable SCAD patients, while urgent revascularization should be considered in hemodynamically unstable patients. Eleven cases of SCAD in COVID-19 patients have already been described: although the exact pathophysiological mechanism remains unclear, COVID-19-related SCAD is considered a combination of significant systemic inflammatory response and localized vascular inflammation. We present a literature review of SCAD, and we report an unpublished case of SCAD in a COVID-19 patient.
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