Spontaneous coronary artery dissection and sudden cardiac arrest: a reversible event or an indication for secondary
Giacomo Mugnai1, Pietro Francia2, Laura Perrotta3
1Division of Cardiology, Heart-Lung and Vascular Department, University Hospital of Verona, Verona.
Insights
Spontaneous coronary artery dissection (SCAD) can cause cardiac arrest (CA). For high-risk SCAD patients with CA, implantable cardioverter-defibrillators (ICDs) may be considered for secondary prevention after careful evaluation.
Area of Science:
- Cardiology
- Cardiovascular Medicine
- Interventional Cardiology
Background:
- Spontaneous coronary artery dissection (SCAD) is a growing cause of acute coronary syndrome (ACS), especially in young women.
- A subset of SCAD patients experience cardiac arrest (CA), posing complex management challenges.
- Existing guidelines offer limited direction on implantable cardioverter-defibrillators (ICDs) for ventricular arrhythmias (VA) from SCAD.
Purpose of the Study:
- To critically review the evidence for and against ICD implantation in SCAD survivors presenting with CA.
- To evaluate the role of ICDs in secondary prevention for SCAD-related life-threatening ventricular arrhythmias.
- To inform clinical decision-making for high-risk SCAD patients with cardiac arrest.
Main Methods:
- Systematic review and critical analysis of existing literature.
- Evaluation of data on appropriate ICD therapy rates in SCAD survivors.
- Assessment of recurrent SCAD risk and underlying arteriopathy in affected patients.
Main Results:
- The rate of appropriate ICD therapy in SCAD survivors is generally low.
- Recurrent SCAD risk remains significant (10-30%) even after acute dissection healing.
- Systemic arteriopathy in SCAD patients suggests a persistent substrate for arrhythmias.
Conclusions:
- Cardiac arrest in SCAD patients may indicate a durable arrhythmic substrate.
- ICD implantation for secondary prevention should be considered in selected high-risk SCAD patients with CA.
- Comprehensive risk assessment and shared decision-making are crucial before ICD implantation.
Abstract:
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly in young women. A high-risk subset of these patients presents with cardiac arrest (CA), creating a profound clinical management dilemma. Current guidelines for secondary prevention with an implantable cardioverter-defibrillator (ICD) offer limited guidance for life-threatening ventricular arrhythmias (VA) secondary to putatively 'reversible' causes such as SCAD. This review critically analyzes the evidence for and against ICD implantation. While the observed rate of appropriate ICD therapy in SCAD survivors is low, the risk of recurrent SCAD is significant (10-30%). Although the acute dissection may heal, the underlying systemic arteriopathy represents a persistent, nonreversible substrate. Therefore, for a selected, high-risk cohort of SCAD patients presenting with CA, the event might be considered a marker for a durable arrhythmic substrate. In these cases, an ICD implantation for secondary prevention should be considered after a comprehensive risk assessment and shared decision-making.
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