SPONTANEOUS CORONARY

ARTERY DISSECTION

An epicardial coronary artery

dissection that is not associated
with atherosclerosis or trauma and
not iatrogenic.

Circulation. 2018;137:e523–e557
 PREVALENCE
 The true prevalence of SCAD remains uncertain, primarily
because it is an underdiagnosed condition.

 SCAD most commonly occurs in patients with few or no

traditional cardiovascular risk factors.

 SCAD may be a cause of up to 1% to 4% of ACS cases

overall.

 occurs overwhelmingly in women(80-90%) and cause of

ACS in up to 35% of MIs in women ≤50 years of age

 Most common cause of pregnancy-associated MI (43%)

Am J Cardiol. 2015;116:66–73.
MECHANISM
ASSOCIATED
CONDITIONS
FREQUENCY OF PRESENTING SYMPTOMS
OF ACUTE SPONTANEOUS CORONARY
ARTERY DISSECTION
 DIAGNOSIS
 Accurate diagnosis of SCAD in the early stages of ACS
presentation is important because management and
investigation are different from those for atherosclerotic forms of
coronary artery disease.

 The suspicion for SCAD is typically instigated by clinical

presenting features such as patient demographics, especially
young age, female sex, and few or no conventional
cardiovascular risk factors.

 Once SCAD is suspected, coronary angiography should be

performed as early as feasible, especially in the setting of ST-
segment–elevation MI
 DIAGNOSIS

Type 1, multiple radiolucent lumens (arrow) or arterial wall contrast staining.

B, Type 2, diffuse stenosis that can be of varying severity and length
(dissection starting from arrow). C, Type 3: focal or tubular stenosis (arrow),
usually<20 mm which mimics atherosclerosis. D. OCT showing intramural
hematoma in type 3.
IMAGING IN PATIENTS WITH SPONTANEOUS
CORONARY ARTERY DISSECTION
 MANAGEMENT
 There substantial evidence that the majority of SCAD will first
stabilize and then heal completely over time if managed
conservatively
 Revascularization in patients with SCAD is very challenging
due to the presence of an underlying disrupted and friable
coronary vessel wall. This is widely reported to lead to worse
outcomes for PCI than in atherosclerotic coronary disease.
 Revascularization is not mandated in haemodynamically
stable patients with maintained distal flow in the culprit
coronary and without demonstrable ongoing ischaemia.
 As the majority of cases failing a conservative management
strategy occur early during follow-up, prolonged inpatient
monitoring (5 days) in conservatively managed SCAD is
suggeste

 MEDICAL MANAGEMENT
 Thrombolysis: Thrombolysis is therefore contraindicated for the
acute management of SCAD.

 Antiplatelet: Patients who undergo stenting should receive

dual antiplatelet therapy for 12 months and prolonged or
lifelong monotherapy In patients managed conservatively,
acute dual antiplatelet therapy is indicated however the
optimal duration of dual and subsequent monotherapy
remains unknown.

 ACEI/ BB/MRA: Left Ventricular Dysfunction

 Statins: Statins are reserved for patients with conventional

indications for treatment independent of their SCAD event.
POST SPONTANEOUS CORONARY ARTERY
DISSECTION CHEST PAIN AND ITS
MANAGEMENT
 PREGNANCY-ASSOCIATED SCAD
 The majority of pregnancy-associated SCADs occur in
the first 4 weeks after delivery, but SCAD has been
reported during virtually all stages of pregnancy.

 Despite the special situation presented by pregnancy,

the principles of SCAD management are largely the
same as for non–pregnancy-associated SCAD

 Early and careful angiography to avoid iatrogenic

dissection and to confirm the diagnosis and aiming for
conservative management if there is no evidence of
ongoing ischemia or infarction, hemodynamic instability,
or particularly high-risk anatomy.
 MANAGEMENT OF
ABNORMAL UTERINE
BLEEDING AFTER SCAD
 FOLLOW UP IMAGING FOR
EXTRACORONARY ABNORMALITIES

Extracoronary abnormalities in spontaneous coronary artery

dissection including renal (A and D) and femoral (B)
fibromuscular dysplasia, carotid and vertebrobasilar aneurysms
and tortuosity (C and F) and a localised iliac dissection (E).
 SPONTANEOUS CORONARY ARTERY
DISSECTION: CLINICAL OUTCOMES AND
RISK OF RECURRENCE
327 troponin-positive ACS patients with nonatherosclerotic SCAD
treated at a single institution, 2012-2016.

 MACE rate at 3 years was 19.9%, primarily in the form of MI;

recurrent SCAD was seen in 10.4%
 Patients with hypertension at baseline were twice as likely to
have a recurrence (HR 2.46; 95% CI 1.23-4.93)
 Beta-blocker use was associated with greatly reduced risk of
recurrent tear (HR 0.36; 95% CI 0.18-0.73)

Implications: Hypertension and lack of beta-blocker therapy may be

contributors to the high rate of recurrence of SCAD after initial treatment.

Saw J, et al. J Am Coll Cardiol. 2017;70:1148–1158.

 Associated Condition or Factor Reported Prevalence
in Cohort Studies, %
Fibromuscular dysplasia 25–8613,29,33,34
Pregnancy 2–88,9,13,33
Multiparity (≥4 births) 8.9–1013,33
Inherited arteriopathy and connective tissue 1.2–3.08,13
disorder (see Table 4)
Marfan syndrome, Loeys-Dietz syndrome, vascular
Ehlers-Danlos syndrome, α1- antitrypsin deficiency,
polycystic kidney Disease
Exogenous hormones 10.7–12.68,13
Oral contraceptives, postmenopausal
therapy, infertility treatments, testosterone,
corticosteroids
Systemic inflammatory disease <1–8.99,13
Systemic lupus erythematosus, Crohn
disease, ulcerative colitis, polyarteritis
nodosa, sarcoidosis, Churg-Strauss syndrome,
Wegener granulomatosis, rheumatoid
arthritis, Kawasaki disease, celiac disease
 Associated Condition or Factor Reported Prevalence
in Cohort Studies, %
Migraine headache NR
Coronary artery spasm NR
Precipitating factors >50% Patients recall a
precipitating factor13
Intense exercise (isometric or aerobic)
Intense Valsalva
Retching, vomiting, bowel movement,
coughing, lifting heavy objects
Intense emotional stress
Labor and delivery
Recreational drugs (cocaine,
methamphetamines)
Exogenous hormones/hormone modulators
β-hCG injections, corticosteroid injections,
clomiphene