Spontaneous Coronary Artery Dissection

Tweet, Marysia S.; Eleid, Mackram F.; Best, Patricia J.M.; Lennon, Ryan J.; Lerman, Amir; Rihal, Charanjit S.; Holmes, David R.; Hayes, Sharonne N.; Gulati, Rajiv

doi:10.1161/circinterventions.114.001659

Cited by 525 publications

(344 citation statements)

References 24 publications

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“…In the setting of SCAD, the rate of procedural success of PCI is low: in a large retrospective analysis of 189 patients presented with SCAD a 53% of technical failure of PCI was reported and 13% of patients initially treated with PCI underwent an emergent CABG [58]. In this cohort, PCI failed to protect against repeated revascularization or recurrent SCAD.…”

Section: Percutaneous Coronary Interventionmentioning

confidence: 95%

“…In general, the first-line approach consists of a conservative medical therapy [1]. This widespread opinion depends on the evidence that angiographic healing occurs in the majority of cases, varying from 73% to 90% and reaching 100% if the control angiography is performed 26 days after SCAD onset [42,58]. Figure 3a).…”

Section: Treatmentmentioning

confidence: 99%

“…The need for revascularization is driven by angiographic and clinical aspects: in case of ongoing myocardial ischemia, persistent ST elevation, hemodynamic instability, complicated ventricular arrhythmias, an invasive approach is advocated, particularly when left main or the proximal tracts of the major coronary arteries are involved [1]. On the basis of observational studies only 17% to 20% of patients with a definite diagnosis of SCAD are treated invasively, including the 3.5% to 10% of patients initially treated conservatively and subsequently undergoing an invasive in-hospital revascularization for recurrent ischemia [41,58,59]. …”

Section: Treatmentmentioning

confidence: 99%

“…In this cohort, PCI failed to protect against repeated revascularization or recurrent SCAD. On the basis of, these findings, a conservative approach and a prolonged observation is currently recommended [58].…”

Section: Percutaneous Coronary Interventionmentioning

confidence: 99%

“…Procedural success is high because of the relatively young age of patients, the usual absence of comorbidity and of coronary atherosclerosis and calcification. In a small cohort of patients Tweet et al observed only a 6% unsuccessful grafting in the setting of SCAD [58]. The long-term results are less encouraging, as at a median 3.5 years follow-up a consistent part of grafts were closed and CABG did not demonstrate to protect against recurrent SCAD or target vessel revascularization [58].…”

Section: Percutaneous Coronary Interventionmentioning

confidence: 99%

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How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

Pepe¹,

Cecere²,

Napodano³

et al. 2017

Interv Cardiol J

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AbstarctSpontaneous coronary artery dissection (SCAD) is a separation of the coronary wall layers, not related to trauma, medical procedures or atherosclerosis. The dissection causes the blood entry in the vascular wall with the consequent formation of a false lumen and intramural hematoma (IMH). Two pathogenetic mechanisms have been proposed to explain SCAD: a "primary" rupture of coronary endothelium or the rupture of the "vasa vasorum". Clinical presentation and severity of manifestations are variable, ranging from complete absence of symptoms to acute coronary syndrome (ACS), cardiogenic shock, cardiac arrest or sudden cardiac death. Despite coronary angiography is the first-line examination, by supplying two-dimensional images of the lumen, it does not always allow an incontrovertible diagnosis of SCAD. New intravascular imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS), have been recently introduced and may be extremely helpful in assessing the coronary wall integrity, thus improving coronary angiography diagnostic accuracy.Because of the lack of large randomized trials comparing different strategies, the optimal treatment of SCAD is still controversial. The first-line approach is conservative and based on medical therapy. Nevertheless, in particular situations an invasive approach is necessary. In the last years, several new strategies have improved the way to perform percutaneous coronary interventions (PCI), such as new generation drug eluting stents (DES), bio-resorbable scaffolds (BRS), sirolimus self-expandable stent (SES), drug eluting balloons (DEB), and cutting balloon. Cardiac artery bypass graft (CABG) is an even more invasive method to restore coronary flow and should be considered in urgent/emergent settings when PCI is not feasible or has failed.Cause the therapeutic approach of SCAD can be substantially different from that of atherosclerotic coronary artery disease, an accurate diagnosis is crucial to set up the best treatment strategy.

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Section: Percutaneous Coronary Interventionmentioning

confidence: 95%

Section: Treatmentmentioning

confidence: 99%

Section: Treatmentmentioning

confidence: 99%

Section: Percutaneous Coronary Interventionmentioning

confidence: 99%

Section: Percutaneous Coronary Interventionmentioning

confidence: 99%

See 3 more Smart Citations

How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

Pepe¹,

Cecere²,

Napodano³

et al. 2017

Interv Cardiol J

View full text Add to dashboard Cite

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A Young Woman With Chest Pain

Youmans

Unger

Benzuly

2018

JAMA

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A 36-year-old healthy gravida 3, para 3 woman with a history of asthma and elective cesarean delivery 11 days prior presented to the emergency department with 3 days of exertional chest pain. The pain was described as crushing and substernal, but she denied radiation or associated dyspnea, nausea, vomiting, or diaphoresis. On physical examination, her blood pressure was 167/105 mm Hg bilaterally, heart rate was 71/min, respiratory rate 18/min, and oxygen saturation 98% on room air. Initial laboratory evaluation revealed a troponin I level of 0.12 ng/mL (reference range, 0.00-0.04 ng/mL). An electrocardiogram showed normal sinus rhythm with diffuse ST-segment depressions but without q waves or ST-segment elevation (Figure, left). Computed tomography angiography did not show pulmonary embolism or aortic dissection. Echocardiography demonstrated a left ventricular ejection fraction of 53%, with apical akinesis and no valvular disease.The patient was started on aspirin and ticagrelor, heparin infusion, and metoprolol tartrate for treatment of non-ST-segment elevation myocardial infarction. She underwent coronary angiography (Figure, right; Video).

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