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We thank Dr Kang for reading and commenting1Kang G. Spontaneous coronary artery dissection and exogenous hormone (letter).Ann Thorac Surg. 2020; 109: 1307-1308Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar on our article reporting the coexistence of aortic aneurysm and spontaneous coronary artery dissection (SCAD) in 2 patients of our series.2García-Arribas D. Macaya F. Vilacosta I. Saiz-Pardo M. Escaned J. Viana-Tejedor A. Coexistence of spontaneous coronary artery dissection and ascending aortic aneurysm.Ann Thorac Surg. 2019; 108: e249-e252Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The author1Kang G. Spontaneous coronary artery dissection and exogenous hormone (letter).Ann Thorac Surg. 2020; 109: 1307-1308Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar highlights the potential role of hormonal exposure in these patients, which is undoubtedly an interesting aspect to consider in the yet enigmatic physiopathology of SCAD.3Macaya F. Salinas P. Gonzalo N. Fernández-Ortiz A. Macaya C. Escaned J. Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management.Open Heart. 2018; 5e000884Crossref PubMed Scopus (31) Google Scholar Female preponderance in SCAD and in fibromuscular dysplasia, another vascular disorder often found in patients with SCAD (patient 2 in our report), suggests that a hormonal mechanism contributes to vessel frailty in patients with either of these conditions.4Tweet M.S. Miller V.M. Hayes S.N. The evidence on estrogen, progesterone, and spontaneous coronary artery dissection.JAMA Cardiol. 2019; 4: 403-404Crossref PubMed Scopus (23) Google Scholar Estrogen has important effects in vascular physiology, including enhancement of nitric oxide release and reduction of oxidative stress.5Miller V.M. Duckles S.P. Vascular actions of estrogens: functional implications.Pharmacol Rev. 2008; 60: 210-241Crossref PubMed Scopus (377) Google Scholar On the other hand, estrogen with or without combined progesterone increases the enzymatic activity of matrix metalloproteinases, which can contribute critically in vessel remodeling.6Grandas O.H. Mountain D.H. Kirkpatrick S.S. et al.Regulation of vascular smooth muscle cell expression and function of matrix metalloproteinases is mediated by estrogen and progesterone exposure.J Vasc Surg. 2009; 49: 185-191Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar The latter effect should be investigated further in patients with SCAD or fibromuscular dysplasia, or both, as it could play an instrumental role in the physiopathology underlying these conditions. The effects of hormonal replacement therapy (HRT) in patients with SCAD are unknown.4Tweet M.S. Miller V.M. Hayes S.N. The evidence on estrogen, progesterone, and spontaneous coronary artery dissection.JAMA Cardiol. 2019; 4: 403-404Crossref PubMed Scopus (23) Google Scholar Although some isolated case reports and one single-center study suggest a potential association,7Sharma S. Kaadan M.I. Duran J.M. et al.Risk factors, imaging findings, and sex differences in spontaneous coronary artery dissection.Am J Cardiol. 2019; 123: 1783-1787Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar more consistent data are needed. Moreover, HRT was not noted as a predictor of SCAD recurrence in an observational study by Saw and colleagues.8Saw J. Humphries K. Aymong E. et al.Spontaneous coronary artery dissection.J Am Coll Cardiol. 2017; 70: 1148-1158Crossref PubMed Scopus (289) Google Scholar In our report, the woman in case 2 was not taking HRT at the time of SCAD nor in the past. In any case, for the scenario of SCAD coexisting with arterial aneurysms elsewhere, it seems reasonable to avoid HRT given its abovementioned effects on vascular matrix. Spontaneous Coronary Artery Dissection and Exogenous HormoneThe Annals of Thoracic SurgeryVol. 109Issue 4PreviewI read with great interest the well-presented article by García-Arribas and colleagues.1 They report the characteristics of 2 patients from spontaneous coronary artery dissection (SCAD) cohort that concomitantly presented unruptured ascending aortic aneurysm. Full-Text PDF