Cause Of Acute Coronary Syndrome Research Articles

Clinical outcomes in spontaneous coronary artery dissection

ObjectiveSpontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome. Our aim was to assess adverse events at follow-up from a nationwide prospective cohort.MethodsThe Spanish Registry on...

The presence of thrombus in spontaneous coronary artery dissection: A systematic review of autopsy findings

BackgroundSpontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome in young women. There is no consensus on optimal treatment, though a conservative approach including antiplatelet agents is commonly used. We hypothesized that most cases of SCAD would not demonstrate true lumen thrombus in the dissected artery, suggesting that anti-platelet agents might not have a role in the treatment of SCAD. MethodsWe conducted a systematic review of the published literature through March 2022 to identify pathology images from individuals who died of SCAD. The images were independently reviewed by a pathologist to assess for the presence of thrombus and inflammatory cells. ResultsWe identified 40 cases from 34 publications with available pathology images and found only one case of true lumen thrombus. Additionally, we found that 53% of cases involved eosinophilic inflammation. ConclusionThe role of antiplatelet agents in the treatment of SCAD should be re-evaluated. Further studies are needed to better understand the significance and treatment implications of eosinophilic inflammation.

Spontaneous coronary artery dissection - case series of a rare disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome (ACS) particularly in young women. Female sex, pregnancy, emotional stress and fibromuscular dysplasia are known triggering factors for SCAD. Aim To identify clinical profile, outcomes and recurrence of SCAD within United Arab Emirates (UAE) Methods Prospective, observational collection of data from all patients with diagnosis of SCAD based on angiographic findings. The time period is March, 2020 till February, 2021. Six months follow up data has been recorded (till date). All patients underwent genetic screening for TSR and PHACTR genes however data was available for two patients only at the time of write up. Results (Tables) Conclusion We report positive outcomes of patients presenting with SCAD. Female predominance, non-atherosclerotic risk factors, post-partum & SCAD Type B was seen, which is comparable to western cohorts. Our region may have high incidence of SCAD, given the five cases that we had in short period of recruitment. Abstract Figure. SCAD_E-poster

Causa rara de parada cardíaca: um caso de extensa dissecção espontânea da artéria coronária esquerda

A 28-year-old male with a previous history of drug abuse was sent to an emergent coronary angiography, after a cardiac arrest, with a post-resuscitation eletrocardiogram showing ST-segment elevation from V1-V4. Angiography showed multivessel and multisegment spontaneous coronary artery dissection. Due to clinical instability, patient underwent left anterior descending artery percutaneous coronary intervention. Prevalence of spontaneous coronary artery dissection as the cause of acute coronary syndrome is anecdotal in men. Yet, in the right scenarios as in this case, it must be ruled out. Cardiorespiratory arrest is an uncommon presentation of spontaneous coronary artery dissection and percutaneous coronary intervention in spontaneous coronary artery dissection is still a matter of debate.

ACUTE CORONARY SYNDROME IN A YOUNG FEMALE: A RARE OCCURRENCE WITH CABERGOLINE

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome. Here, we describe SCAD in a 25-year-old female on long-term cabergoline therapy with no other cardiac risk factors. Cabergoline-induced SCAD should be considered in patients presenting with an acute coronary syndrome who are treated with this medication.

Learned Helplessness and Cluster Headache – A Case Report

Spontaneous coronary artery dissection (SCAD) has long been recognized as a cause of acute coronary syndromes (ACS) with very low prevalence (3% in most cohorts). It predominantly occurs in young to middle-aged women. SCAD patients have fewer traditional cardiovascular risk factors for ischaemic heart disease than patients with atherosclerotic coronary artery disease, however, many patients do have some risk factors for ischaemic heart disease including hypertension, smoking, and dyslipidaemia, although there is no evidence these contribute directly to the risk of SCAD. We report in this case an observation of spontaneous coronary dissection, in order to discuss its pathogenesis, diagnosis and management.

Acute coronary syndromes in young patients: Phenotypes, causes and clinical outcomes following percutaneous coronary interventions.

BackgroundThe prevalence of acute coronary syndromes (ACS) among young individuals is increasing, but the phenotypic characteristics, causes and clinical outcomes in this group have not been well described. MethodsBetween 2009 and 2017, 8712 ACS patients underwent percutaneous coronary intervention (PCI) and were prospectively enrolled. We defined a young patient as female <50 years and male <45 years. The causes of ACS were defined by an adjudication committee. The primary endpoint was the patient-oriented composite endpoint (POCE) of all-cause mortality, myocardial infarction or any revascularization at 12 months. ResultsAmong 8712 ACS patients, 472 (5.4%) patients were young (26% female). The main cause of ACS in young patients was atherosclerosis (86.5%), followed by coronary artery embolism (9%), and spontaneous coronary artery dissection (SCAD) (4.5%). POCE occurred less frequently in young compared to old patients (8.5% vs. 16.7%, hazard ratio 0.48 (95% confidence interval 0.35–0.66), p < 0.001). The rates of the individual components of the POCE were lower in young including all-cause mortality (3.2% versus 9.5%, 0.32 (0.19–0.54), p < 0.001), myocardial infarction (1.9% versus 3.7%, 0.49 (0.25–0.95), p = 0.035) and any revascularization (5.1% versus 7.4%, 0.65 (0.43–0.97), p = 0.037). Young patients with SCAD had a higher rate of death as compared to those with atherosclerosis, mainly attributed to cardiac deaths. ConclusionsOne out of 20 ACS patients undergoing PCI was young and the principal cause was atherosclerosis. Young carry a lower risk for future events compared to older ACS patients. The underlying cause leading to ACS should be considered in appropriate risk stratification of young patients.Clinical Trial Registration:Clinicaltrials.gov. NCT02241291

Prevalence, Morphology, and Predictors of Intra-Stent Plaque Rupture in Patients with Acute Coronary Syndrome: An Optical Coherence Tomography Study.

Previous studies have shown that plaque rupture (PR) is the most important cause of acute coronary syndrome (ACS). However, the potential impact of intra-stent PR on stent failure manifesting as ACS and the optical coherence tomography (OCT) features of these lesions was still less clear. Therefore, we aimed to investigate the characteristics of OCT-defined in-stent PR and identify the potential risk factors for PR in ACS patients. All 213 ACS patients were stratified into two groups according to the occurrence of in-stent PR. The baseline characteristics of all patients were investigated. A multivariable logistic regression was performed to identify factors associated with the formation of PR. OCT findings showed that 80 patients had in-stent PR, and 133 patients were without PR. Patients who suffered in-stent PR had higher blood lipid levels (P < .050) and longer duration of stent failure (P = .001). Moreover, thrombolysis in myocardial infarction (TIMI) 0/1 flow was more prone to the formation of PR (P = .010), and lesions in the PR group harbored more macrophages and cholesterol crystals (P < .001 and P = .024). On multivariate analysis, presentation of myocardial infarction (MI) and OCT findings of lipidic neointima length showed a 3.6-fold (P = .004) and 1.3-fold (P < .001) higher risk for occurrence of in-stent PR. ACS patients who suffered in-stent PR had a longer duration of stent failure and more ISR occurring in non-culprit vessels. Given the distinguishing features between ACS patients with in-stent PR and non-PR, potential targeted therapy was warranted to improve the prognosis of patients with in-stent PR.

Molecular basis of acute coronary syndrome.

Cardiovascular diseases (CVD) comprise of various heart and blood vessels-related diseases. Acute coronary syndrome (ACS) is one of them. Basic researchers and cardiologists have witnessed landmark developments related to ACS and despite rapid refinement in our understanding; scientists are seeking answers for more questions. Scientists have mapped wide ranging proteins and intricate protein networks which play central role in the pathogenesis in ACS. In this review, we have attempted to summarize underlying causes of ACS. Better understanding of the disease pathology will enable us to get a step closer to an effective clinical management.

Acute Limb Ischemia as an Unusual Presentation of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare, though, important cause of acute coronary syndrome that is more commonly seen in young and middle-aged women without risk factors for, or a history of, coronary artery disease. Acute embolization of left ventricular (LV) thrombus is an uncommon but known cause of acute limb ischemia. In this case, we present a rare case of SCAD that led to acute limb ischemia due to embolization of LV thrombus.

The Self Sabotaging Vessel: A Case Report and Literature Review of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndrome. Despite the recent advances in the management of cardiovascular diseases, the diagnoses and management of SCAD remain a dilemma. It has been described to majorly affect females of childbearing age, immediately post-partum or on oral contraceptives. Recent cases have also identified underlying connective tissue disease as a risk factor. Since its discovery, only a limited number of cases affecting males have been reported in the literature. This makes our case unique. In this, we present a 31-year-old male without any traditional risk factors who presented with atypical chest pain. Electrocardiogram showed ST-segment changes with echocardiogram revealing apical left ventricular akinesis. A diagnostic left heart catheterization showed multiple lumens in the distal left anterior descending artery (LAD). The patient was managed conservatively and discharged home on guideline-directed medical therapy.

The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population.

Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners. Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics. Of 1196subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients. With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.

Clinical Features and Prognoses of Middle-Aged Women With ST-Elevation Myocardial Infarction With a Focus on Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) has become an increasingly recognized cause of acute coronary syndrome, particularly in young women, over the last decade. The goal of this study was to determine the prognoses and characteristics of adult women with SCAD who presented with ST-elevation myocardial infarction (STEMI). This retrospective cohort study enrolled all adult women under the age of 60 who had undergone coronary artery angiography in the setting of STEMI. The patients were divided into 3 groups based on their angiographic characteristics: STEMI-SCAD (STEMI due to SCAD), STEMI-ATH (STEMI caused by an atherosclerotic lesion), and STEMI-others (STEMI due to other etiologies including Takotsubo cardiomyopathy and myopericarditis, as well as STEMI despite a normal epicardial coronary angiography). Fifteen women out of 311 female patients aged below 60 years with STEMI were diagnosed with SCAD (4.8%). There were no significant differences in body mass index, hypertension, dyslipidemia, smoking status, opium addiction status, family history, previous percutaneous coronary intervention, coronary artery bypass grafting, and cerebrovascular accidents between the STEMI-SCAD and STEMI-ATH groups. Nevertheless, the STEMI-SCAD and STEMI-others groups were more likely to be younger, less likely to be diabetic, and less likely to have 3 cardiovascular risk factors or more than was the STEMI-ATH group. The left anterior descending artery was the most common culprit lesion in the STEMI-SCAD group (80%) and the other 2 groups. Out of the 311 patients, 7 patients died during the index hospitalization: 1 patient in the STEMI-SCAD group, 6 patients in the STEMI-ATH group, and 0 patients in the STEMI-others group. None of the patients in the STEMI-others group experienced any major adverse cardiac events during the follow-up. In the other 2 groups, the most experienced outcomes were myocardial infarction and in-hospital cardiac death, followed by target lesion revascularization and target vessel revascularization. STEMI-SCAD is one of the known causes of STEMI in young women. Still, despite the complexity of revascularization in our patients with STEMI-SCAD, they had more favorable prognoses in both conservative and revascularization management modalities than our patients with STEMI-ATH.

593 Spontaneous coronary artery dissection in young

Abstract Aims We present the case of a 25 years-old patient, presented to the Emergency Department for chest pain and epigastralgia complicated by vomiting. Symptoms started about 30 h before, afterwards an effort. The patient did not have any known cardiovascular risk factors (except for sporadic consumption of cannabis) and family medical history was negative for premature cardiovascular disease or sudden cardiac death. His past medical history was unremarkable. Methods and results Clinical examination was normal. ECG was suggestive for subacute anterior ST-elevation myocardial infarction (QS in V1–V4 leads with ST segment elevation and biphasic T-waves in V4–V6) and was accompanied by significant elevation of myocardial necrosis biomarkers (hsTnT 3416 ng/l, n.v. &amp;lt;15). Echocardiography revealed a severely reduced left ventricular ejection fraction (LVEF = 30%) with regional wall motion abnormalities (apical and septal akinesia, and anterior mid-ventricular segment hypokinesia). Coronary angiography was suggestive for a dissection of the proximal-to-mid left anterior descending artery. Dissection flap, subocclusion of the first septal branch, and intramural thrombosis were noted. Direct stenting with drug-eluting stent was successful, with thrombolysis in myocardial infarction (TIMI) flow grade 3. The patient was started on dual antiplatelet treatment (aspirin and ticagrelor), ACE-inhibitors, beta blockers, and spironolactone. Further testing ruled out other conditions that may be associated with spontaneous coronary artery dissection (autoimmune diseases, including vasculitis, connective tissue disease, coagulative disorders). The clinical course was complicated by pericarditis and the development of LV apical thrombus. So, patient was started on anticoagulation (warfarin) with subsequently downgrading from ticagrelor to clopidogrel. Echocardiographic follow-up documented a progressive improvement of LVEF (50%), and global longitudinal strain (GLS −15%) with persistence of wall motion abnormalities in the apical and septal segments. Partial resolution of intracavitary thrombi was documented. CMR revealed LV apical aneurysm. Moreover, the use of dedicated sequences showed transmural late gadolinium enhancement in akinetic segments, and fatty metaplasia of the apical portion of the anterior wall and anterior septal wall. Finally, early gadolinium enhancement imaging, confirmed the persistence of LV stratified apical thrombus. Conclusions Spontaneous coronary artery dissection (SCAD) is an underdiagnosed and frequent cause of acute coronary syndrome (ACS) in young-to-middle aged patients, particularly women; therefore, even in young people, a chest pain episode suggestive for an ischaemic cause should never be underestimated. Cardiac magnetic resonance is the most accurate method to evaluate the sequelae of myocardial infarction (including LV size and function, presence of fatty metaplasia, extent and transmurality of ischaemic scar, presence of thrombi), to aid in differential diagnosis and to define prognosis and guide the therapeutic management.

Double Trouble - Spontaneous Coronary Artery Dissection of the Left Anterior Descending and Posterior Descending Arteries in a Right Dominant Circuit: A Case Report

Acute myocardial infarction is a condition that classically presents with chest pain and corresponding biomarkers and changes on electrocardiogram. Although most causes of acute coronary syndrome are due to acute plaque rupture resulting in coronary thrombosis, an increasingly prevalent condition known as spontaneous coronary artery dissection (SCAD) is becoming more commonly diagnosed. SCAD is characterized by a tear in the tunica media resulting in an intramural hematoma. Depending on the size of the hematoma, progressive extension can ultimately lead to coronary occlusion. Our team presents a 52-year-old female patient that presented with substernal chest pain and positive cardiac enzymes. Urgent coronary catheterization revealed bilateral SCAD involving the left anterior descending and posterior descending arteries in a right coronary dominant circuit. Our patient was treated with medical therapy alone and was safely discharged to home after close monitoring in the coronary care unit. Our team hopes to contribute to a growing body of evidence that bilateral SCAD can occur and can be successfully treated without percutaneous coronary intervention. J Med Cases. 2021;12(12):491-494 doi: https://doi.org/10.14740/jmc3774

Diseño y justificación del estudio clínico aleatorizado BA-SCAD (bloqueadores beta y agentes antiplaquetarios en pacientes con disección arterial coronaria espontánea)

Introduction y objectivesSpontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Most patients are empirically treated with beta-blockers and antiplatelet drugs. The Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection (BA-SCAD) is an academic, pragmatic, prospective, randomized, open-label, blinded-endpoint clinical trial, performed under the auspices of the Spanish Society of Cardiology, to assess the efficacy of pharmacological therapy in patients with SCAD. MethodsUsing a 2 x 2 factorial design, 600 patients will be randomized (1:1/1:1) to: a) beta-blockers (yes/no) and b) “short” (1 month) vs “prolonged” (12 months) antiplatelet therapy. Only patients with preserved left ventricular ejection fraction will be randomized to beta-blockers (yes/no) because patients with reduced left ventricular ejection fraction will receive beta-blockers according to current guidelines. Similarly, only conservatively managed patients (ie, no coronary intervention) will be randomized to the antiplatelet stratum, as patients requiring coronary interventions will receive 1-year dual antiplatelet therapy. The primary efficacy endpoint includes a composite of death, myocardial infarction, stroke, coronary revascularization, recurrent SCAD, and unplanned hospitalization for acute coronary syndrome or heart failure at 1 year. The primary safety endpoint will be bleeding. All patients will be clinically followed up yearly. A comprehensive set of additional substudies (clinical, imaging, revascularization, biomarkers, inflammatory, immunologic, pharmacogenetics, and genetic) will be conducted to ensure a holistic view of this unique and challenging clinical entity. ConclusionsThe results of the BA-SCAD randomized clinical trial will advance our knowledge in the treatment of patients with SCAD.The study was registered at ClinicalTrials.gov (Identifier: NCT04850417).

Abstract 11949: Disease-Specific and Comorbidity-Related Polygenic Risk in Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute coronary syndrome that typically affects younger women (24-52 years). Several comorbidities have now been reported, including migraine, fibromuscular dysplasia (FMD), connective tissue disorders, anxiety, and depression. Associations between SCAD and other conditions, such as autoimmune disorders, have been reported but remain contentious. SCAD is known to have a genetic element: both common and rare variants have been associated with the disease and familial clustering has been identified. However, the genetic etiology is not well resolved although common variants have been identified between SCAD, FMD, and migraine. Aims: We sought to determine if there is a polygenic disease burden of common genetic variation in a cohort of sporadic SCAD cases, and shared genetics between SCAD and reported comorbidities via the application of polygenic risk scores (PRSs) for these comorbidities. Methods: A cohort of 173 sporadic European SCAD cases and 1314 European controls were genotyped (88 cases, 1127 healthy elderly controls and 76 non-SCAD cardiomyopathy-diseased patients by whole genome sequencing; 85 cases and 111 controls by Axiom UK Biobank and PMDA array, respectively). Differences in genetic risk was assessed for cases and controls using established PRS, specific to either SCAD or conditions reported to be comorbid. Results: SCAD cases showed significantly higher SCAD-PRS than did controls (WGS p = 1.372e-09; array p = 5.264e-05). In contrast, there were no differences in SCAD-PRS between non-SCAD patients and controls (WGS only: p-value = 0.291) and non-SCAD patients also had lower risk than SCAD cases (WGS only: p-value = 2.08e-07). Multiple PRS derived from comorbid disorders are currently being investigated in this cohort. Conclusions: We have shown that there is a common genetic risk element to SCAD, while genetic risk for, and, therefore, genetic overlap with, reported comorbidities in SCAD will be further discussed. These findings illustrate the role of common variants in SCAD etiology and may further contribute to our understanding of the mechanisms leading to SCAD formation.

Abstract 14075: Infective Endocarditis Associated With Irreversible Coronary Spasm and Cardiac Arrest

Introduction: Coronary artery spasm (CAS) can elicit ischemia with transient ST-segment deviation that usually responds to nitrates; however, CAS can precipitate arrhythmias leading to sudden cardiac arrest. Infective endocarditis (IE) is associated with the acute coronary syndrome (ACS) usually via coronary embolism and compression secondary to peri-annular complications. CAS in association with IE causing ACS is extremely rare. Case: A 54-year-old man had a recent ST-elevation (STE) myocardial infarction, which required stenting to obtuse marginal artery (OM2) artery. He presented with a fever for one week. A new diastolic murmur at the aortic area on examination. Echocardiography showed a bicuspid aortic valve with perforation and new-onset aortic regurgitation suggestive of vegetation. Diagnosis of infective endocarditis was established, and the patient was started on medical treatment and was being prepared for surgical repair. During the hospital stay, he had recurrent episodes of severe chest pain accompanied by transient STE on ECG but normal troponin level. It was always responding to sublingual nitrates. CT coronary Angiogram showed no significant coronary stenosis and patent stent in OM2. The patient had again an attack of severe chest pain with ECG showed extensive STE then he developed pulseless electrical activity. Result: Resuscitation was started and emergency coronary angiography was performed and showed severe spasms in both LAD and LCX with TIMI-1 flow. A repeated image during resuscitation showed patent arteries with TIMI-III flow. A prolonged CPR in Cath-lab failed and the patient died. Although there was no clear explanation of the mechanism, the simultaneous association between the CAS and IE raises the suspicion of a possible relationship between both pathologies. Conclusions: Severe coronary spasm should be considered as a possible cause of ACS in association with IE.

Abstract 12376: Coronary Artery Bypass Graft Surgery in Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome. While most patients are managed conservatively, some patients may require percutaneous or surgical revascularization. Limited data exist on SCAD patients referred for coronary artery bypass graft (CABG) surgery. Hypothesis: Examine the clinical characteristics, management, and outcomes of SCAD patients referred for CABG. Methods: Retrospective study of patients enrolled in the Mayo Clinic SCAD Registry between 2010-2020 who underwent CABG during the initial management of acute SCAD episode. Results: Among the 81 patients with SCAD referred for CABG, 3 (4%) were men, mean age was 40.6 +/- 8.4 years; the majority were white (91%), and 24 (30%) had pregnancy-associated SCAD (P-SCAD). The most common presenting symptom was chest pain 80 (99%); 57 (70%) presented with ST elevation myocardial infarction (STEMI), and 21 (26%) presented with non-ST elevation MI. Multivessel dissection occurred in 40 (49%), left anterior descending artery (LAD) involvement occurred in 66 (81%) and left main (LM) in 32 (40%). Left ventricular ejection fraction was &lt;50% in 40 patients (49%) at time of initial SCAD. The most common reasons for CABG were the presence of high-risk anatomy (56%), hemodynamic instability/active ischemia (7%), failed PCI (9%), and other/unknown (12%). Most patients received venous plus arterial bypass grafts 42 (52%), saphenous vein grafts in 20 (25%), and left internal mammary artery in 17 (21%). Screening for underlying arteriopathy was performed in 50 (62%) of whom 29 (36%) had fibromuscular dysplasia. Recurrent SCAD occurred in 10 (12%) after an average of 6.2 +/- 5 years after initial SCAD. Of those with recurrent SCAD, none required repeat surgical revascularization and 6 required percutaneous intervention (PCI). There were no deaths. Conclusions: Patients undergoing CABG for SCAD commonly present with STEMI, LM, or multivessel dissection, and failed percutaneous intervention attempts. In addition, CABG for P-SCAD was more frequent than expected and may relate to the increased prevalence of multivessel dissection. CABG was associated with low mortality, but recurrent SCAD may still occur.

Abstract 10398: Clot or Not? A Meta-Analysis of Autopsy Findings in Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is an uncommon but likely underdiagnosed cause of acute coronary syndrome. Current treatment of SCAD commonly includes antiplatelet agents, though pathogenesis relates to intramural hematoma, rather than atherothrombosis as in typical myocardial infarction. Our goal was to determine whether thrombus in the true lumen is part of the pathophysiology of fatal cases of SCAD, which could help guide treatment decisions. Methods: A review of electronic databases including PubMed and EMBASE was conducted from inception through June 2021. Citations were included that provided pathology images of dissected coronary arteries acquired from autopsies of patients who died of SCAD. Images were independently reviewed by a pathologist who described the presence or absence of thrombus and inflammatory cells. Results: A total of 35 citations containing autopsy images were identified. These included 42 cases of which 88% were female, with an average age of 44 years. The most common vessel involved was the left anterior descending (74%), with 40% involving multiple vessels. Most decedents had no medical history, though 5% had systemic vasculitis and 17% were pregnant or peri-partum. On independent review of the pathology images, all had intramural hematoma, none had evidence of thrombus in the true lumen, and 16% had evidence of thrombus in the false lumen. There was eosinophilic inflammation of the affected artery in 64% of cases. Conclusions: There was no evidence of thrombus in the true lumen in any of 42 cases of fatal SCAD for whom autopsy images were available. This suggests that the use of antiplatelet agents in the treatment of SCAD should be re-evaluated. Clinical trials are necessary to determine whether antiplatelet agents are beneficial for patients with SCAD. Additionally, further research is necessary to better understand the role of eosinophils in the pathophysiology of SCAD.