Spontaneous coronary artery dissection: dissecting an underdiagnosed problem
Deborah N Kalkman1, Arja S Vink2, Marcel A M Beijk2
1Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands. d.n.kalkman@amsterdamumc.nl.
Insights
Spontaneous coronary artery dissection (SCAD) affects 1-4% of acute coronary syndromes, primarily premenopausal women. Treatment involves antiplatelet therapy and beta-blockers, with a 10-20% recurrence rate despite medical management.
Area of Science:
- Cardiology
- Vascular Medicine
Background:
- Spontaneous coronary artery dissection (SCAD) accounts for 1-4% of acute coronary syndromes (ACS).
- SCAD involves intramural hematoma compressing the coronary artery lumen, causing ischemia or myocardial infarction.
- It predominantly affects premenopausal women lacking traditional atherosclerosis risk factors.
Purpose of the Study:
- To summarize the current understanding of SCAD, including diagnosis, management, and outcomes.
- To highlight the association between SCAD and fibromuscular dysplasia (FMD).
- To inform evidence-based treatment strategies and future research directions.
Main Methods:
- Diagnosis relies on invasive coronary angiography, often supplemented by optical coherence tomography or intravascular ultrasound.
- Risk factor assessment includes screening for fibromuscular dysplasia (FMD) via CT angiography.
- Treatment recommendations are largely based on expert consensus and observational data.
Main Results:
- Coronary intervention is typically reserved for complete artery occlusion with persistent ischemia.
- Long-term medical management includes antiplatelet agents and beta-blockers, often lifelong.
- Recurrence rates range from 10-20% within 4 years, and nearly two-thirds of patients have associated FMD.
Conclusions:
- SCAD management requires a multidisciplinary approach, including antiplatelet therapy, beta-blockers, and FMD screening.
- Patients may benefit from ACE inhibitors or aldosterone receptor blockers if left ventricular systolic dysfunction is present.
- Ongoing randomized controlled trials aim to establish definitive treatment guidelines for SCAD.
Abstract:
Spontaneous coronary artery dissection (SCAD) occurs in 1-4% of acute coronary syndromes (ACS). In SCAD, an intramural hematoma compresses the true lumen of the coronary artery, leading to ischemia and, even acute myocardial infarction.Approximately, 90% percent of SCAD patients are premenopausal women without classical risk factors for atherosclerosis. The gold standard for diagnosis is invasive coronary angiography and optical coherence tomography or intravascular ultrasound can be useful tools to confirm the diagnosis. Coronary intervention with stent placement is generally not recommended unless there is complete occlusion of the coronary artery with ongoing ischemia. In the acute phase, antiplatelet therapy and beta-blockers are advised, which are usually continued for life. Despite medical treatment, 10-20% of SCAD patients experience a recurrence within 4 years. Nearly two-thirds of SCAD patients have fibromuscular dysplasia (FMD) based on CT angiography. Current treatment recommendations are based on expert opinion. Therapy and follow-up are advised to include at least one antiplatelet agent, a beta-blocker, screening for FMD, cardiac rehabilitation and among patients with left ventricular systolic dysfunction ACE inhibitor or aldosterone receptor blocker. Randomized controlled trials have been initiated to evaluate the treatment effects of beta-blocker and antiplatelet therapy in SCAD patients.
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