Acute Spontaneous Coronary Artery Dissection Research Articles

Differential miRNAs in acute spontaneous coronary artery dissection: Pathophysiological insights from a potential biomarker

BackgroundSpontaneous Coronary Artery Dissection (SCAD) is an important cause of acute coronary syndromes, particularly in young to middle-aged women. Differentiating acute SCAD from coronary atherothrombosis remains a major clinical challenge. MethodsA case-control study was used to explore the usefulness of circulating miRNAs to discriminate both clinical entities. The profile of miRNAs was evaluated using an unbiased human RT-PCR platform and confirmed using individual primers. miRNAs were evaluated in plasma samples from acute SCAD and atherothrombotic acute myocardial infarction (AT-AMI) from two independent cohorts; discovery cohort (SCAD n = 15, AT-AMI n = 15), and validation cohort (SCAD n = 11, AT-AMI n = 41) with 9 healthy control subjects. Plasma levels of IL-8, TGFB1, TGBR1, Endothelin-1 and MMP2 were analysed by ELISA assays. FindingsFrom 15 differentially expressed miRNAs detected in cohort 1, we confirmed in cohort 2 the differential expression of 4 miRNAs: miR-let-7f-5p, miR-146a-5p, miR-151a-3p and miR-223-5p, whose expression was higher in SCAD compared to AT-AMI. The combined expression of these 4 miRNAs showed the best predictive value to distinguish between both entities (AUC: 0.879, 95% CI 0.72–1.0) compared to individual miRNAs. Functional profiling of target genes identified an association with blood vessel biology, TGF-beta pathway and cytoskeletal traction force. ELISA assays showed high plasma levels of IL-8, TGFB1, TGFBR1, Endothelin-1 and MMP2 in SCAD patients compared to AT-AMI. InterpretationWe present a novel signature of plasma miRNAs in patients with SCAD. miR-let-7f-5p, miR-146a-5p, miR-151a-3p and miR-223-5p discriminate SCAD from AT-AMI patients and also shed light on the pathological mechanisms underlying this condition. FundingSpanish Ministry of Economy and Competitiveness (MINECO): Plan Nacional de Salud SAF2017-82886-R, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Fundación BBVA a equipos de Investigación Científica 2018 and from Caixa Banking Foundation under the project code HR17-00016 to F.S.M. Instituto de Salud Carlos III (AES 2019): PI19/00565 to F.R, PI19/00545 to P.M. CAM (S2017/BMD-3671-INFLAMUNE-CM) from Comunidad de Madrid to FSM and PM. The UK SCAD study was supported by BeatSCAD, the British Heart Foundation (BHF) PG/13/96/30608 the NIHR rare disease translational collaboration and the Leicester NIHR Biomedical Research Centre PI17/01865, Instituto de Salud Carlos III and FEDER (European Regional Development Fund).

Characteristic findings of acute spontaneous coronary artery dissection by cardiac computed tomography.

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS); however, its detection carries relevant clinical implications. Cardiac computed tomography (CCT) has been found to be useful for follow-up, but data during the acute phase are scarce. Thus, our aim was to evaluate the early diagnostic ability of CCT to detect SCAD. We retrospectively analyzed all the in-hospital CCT performed in a prospective cohort of patients with SCAD from 2012 to 2016. An independent expert blindly evaluated the studies and described the radiologic characteristics of the lesions. These features were compared with the invasive coronary angiography (ICA) and optical coherence tomography (OCT) findings. 18 lesions were analyzed from 12 episodes identified in 11 patients (100% females; median age of 57 years old). CCT recognized the presence of SCAD in 14 (78%) of the lesions, with four different morphological patterns. Most commonly (10, 71%) SCAD presented as a diffuse lumen narrowing surrounded by a 'sleeve-like' wall thickening, which corresponded to intramural hematoma in OCT evaluation. When compared with ICA, CCT showed a positive correlation (Spearman's Rho = 0.775; P = 0.001) and excellent concordance (ICC = 0.8; P = 0.004) in stenosis grading, but not for lesion length and minimal luminal area. CCT was able to identify the presence of SCAD in most of the patients in the acute phase of this elusive and challenging clinical entity. In addition, in this setting, CCT revealed unique and distinct radiologic features and provided a precise assessment of lesion severity.

Usefulness of Cardiac Magnetic Resonance Imaging in Patients With Acute Spontaneous Coronary Artery Dissection

Cardiac magnetic resonance (CMR) has significant diagnostic and prognostic utility in myocardial infarction evaluation. However, its application in spontaneous coronary artery dissection (SCAD) is not described. Patients with confirmed SCAD who had CMR performed within 8 days of the index SCAD were reviewed. Clinical variables including demographics and medical history were recorded. CMR indexes, including myocardial delayed enhancement (MDE), microvascular obstruction, perfusion defects, left ventricular ejection fraction, and wall motion score index were measured. A total of 18 patients (all women, mean age 47.1 years) were included. Overall burden of atherosclerotic risk factors was low; 3 had a previous SCAD. Two patients underwent CMR before coronary angiography, whereas the others received CMR thereafter. Mean time between SCAD diagnosis and CMR completion was 2.7 days (range 0 to 8). Mean left ventricular ejection fraction and wall motion score index were 56.1% and 1.27, respectively. A total of 15 patients had MDE consistent with myocardial infarction in the SCAD distribution(s) identified on coronary angiography, with 8 patients having concomitant microvascular obstruction. Ten patients had transmural MDE. At follow-up (mean 386 days), all patients were alive; extracoronary vascular abnormalities were identified in 14; 6 had recurrent chest pain; and 2 had recurrent SCAD. Both patients with recurrent SCAD had no unique features on CMR to predict a future event. In conclusion, CMR provided significant value in clarifying the diagnosis and assessing for adverse sequelae after acute SCAD. Further studies are needed to determine its role in SCAD prognostication.

Spontaneous coronary artery dissection: Acute findings on coronary computed tomography angiography.

The coronary computed tomography angiography features of acute spontaneous coronary artery dissection, an important cause of acute coronary syndrome in young women, have not been assessed. The "Virtual" Multicenter Mayo Clinic Spontaneous Coronary Artery Dissection Registry was established in 2010 and includes retrospective and prospective patient data. Retrospective assessment of acute coronary computed tomography angiography images was performed for 14 patients (16 vessels) who had images performed within two days of invasive coronary angiography diagnosis of acute spontaneous coronary artery dissection. Four pertinent diagnostic coronary features of acute spontaneous coronary artery dissection were observed in order of prevalence: 1) abrupt luminal stenosis (64%); 2) intramural hematoma (50%); 3) tapered luminal stenosis (36%); and 4) dissection (14%). Additional findings include epicardial fat stranding (42%), coronary tortuosity (29%), and coronary bridge (14%). Fifty percent of patients had myocardial hypoperfusion in the myocardial distribution of the dissected coronary artery. We define key coronary computed tomography angiography features of acute spontaneous coronary artery dissection, the most common of which are abrupt luminal stenosis and intramural hematoma. Importantly, intramural hematoma appears similar to noncalcified atherosclerotic plaque, emphasizing the importance of invasive coronary angiography for acute diagnosis of spontaneous coronary artery dissection until the sensitivity and specificity of coronary computed tomography angiography is better understood.

Abstract 18315: Percutaneous Coronary Intervention versus Conservative Therapy for Acute Management of Spontaneous Coronary Artery Dissection

Objective: To evaluate outcomes of acute spontaneous coronary artery dissection (SCAD) managed with percutaneous coronary intervention (PCI) or conservative therapy. Background: SCAD is a non-atherosclerotic acute coronary syndrome that typically affects young otherwise healthy females. Whether SCAD with normal vessel flow at presentation should be managed with PCI or conservative therapy remains unknown. Methods: We performed a retrospective study of patients after a first SCAD episode (n=142). We excluded those treated with fibrinolysis (n=12) or coronary artery bypass grafting (CABG, n=8). We evaluated in-hospital and late outcomes in three SCAD groups: Vessel occlusion at presentation treated with PCI (Occ-PCI, n=30); normal vessel flow treated with PCI (NF-PCI, n=34) and those managed conservatively (CON, n=58). Results: Overall mean age was 42+9 years, 91% were female and 41% presented with STEMI. Outcomes are shown in the table below. In Occ-PCI, technical failure occurred in 8/30 (27%), of whom 5 required emergency CABG with one in-hospital death. Comparing NF-PCI with CON, there were no differences in clinical characteristics. Technical failure occurred in 16/34 (47%) of NF-PCI due to failure to cross with wire/device (8/34) or final loss of flow (8/34). Emergency CABG was required in 5 (15%). In CON, 54/58 had an uneventful in-hospital course. Four (7%) exhibited early dissection progression of whom two received PCI and one CABG. Long-term rates of target vessel revascularization, but not recurrent SCAD, were higher in NF-PCI vs CON (26% vs 9%, p=0.02; 24% vs 14%, p=0.23). Conclusions: PCI for acute SCAD is associated with high rates of technical failure and adverse clinical outcomes. In SCAD with normal vessel flow, conservative management may be preferable, with close early observation due to a hazard of progression of dissection. These findings underscore the importance of tailoring therapy to etiology of coronary obstruction.

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Acute Spontaneous Coronary Artery Dissection in the Peripartum Period

Acute Spontaneous Coronary Artery Dissection in the Peripartum Period

Acute Spontaneous Coronary Artery Dissection in the Peripartum Period

c PONTANEOUS CORONARY ARTERY DISSECTION (SCAD) is a rare condition that can lead to blood flow bstruction and acute myocardial ischemia and infarction.1 The orbidity and mortality associated with SCAD in pregnant or ostpartum patients can be high without awareness of the ossibility of this condition and its appropriate treatment. The uthors present a case and review the literature concerning cute SCAD in the peripartum patient.