Management Of Spontaneous Coronary Artery Dissection Research Articles

Abstract 14695: Prevalence of Extracoronary Vascular Abnormalities Among Patients With Spontaneous Coronary Artery Dissection: A Look at Scad Across the Lifespan

Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in young women; however, SCAD has also been described in older patients. Differences in SCAD presentation, cardiovascular risk factors, presence of extracoronary vascular abnormalities (EVAs), and management across the lifespan have been understudied. Methods: Single-center cohort study of consecutive patients seen in a dedicated SCAD clinic. Medical history, radiographic, and angiographic data were collected. All patients underwent brain to pelvis CTA imaging to evaluate for EVAs. Patients were stratified into three age groups: 20-40, 40-60, and ≥60 years. Differences among age groups were evaluated using Kruskal-Wallis tests for continuous variables and Pearson Chi-squared tests or Fisher’s exact tests for categorical variables. Results: 193 patients met inclusion criteria, 94.3% women. Prevalence of hypertension (14.8%, 42.6%, and 60%, p<0.001) and dyslipidemia (11.1%, 37.4%, and 53.3%, p<0.001) increased with age. Precipitating factors were significantly different among age groups (p<0.001) with usual exertion more commonly seen in the older cohort (25.5%, 39%, 73.3%). Peripartum SCAD (40%, 2.5%, 0%) and female sex (94.5%, 95.9%, 80%) were more commonly seen in the younger cohort (p<0.001). Younger patients were more frequently discharged on anticoagulation (10.9%, 0.8%, 0%, p<0.004). There were no significant differences in SCAD presentation, vessel involvement, SCAD management, and EVA prevalence. Procedural complications were not different. Conclusions: Older women who develop SCAD have more typical risk factors for ACS including hypertension, and dyslipidemia. Clinical presentation, vessel distribution, and management of SCAD do not vary across age groups. The prevalence of arteriopathies is high and similar across age groups, underscoring the importance of the evaluation for EVAs following SCAD in patients of all ages.

Abstract 11344: 30-Day Rate of Readmission and Economic Burden Among Patient With Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is an infrequent cause of acute myocardial infarction. SCAD most commonly affects women in their 40s and 50s, though it can occur at any age and can occur in men. Hypothesis: T here is limited data on readmission for SCAD. Therefore, we sought to determine the 30-Day Readmission rate (30-DRr) for SCAD & its impact healthcare utilization in the United States. Methods: Using the 2017 & 2018 National Readmission Database, a retrospective study of patient discharges with Spontaneous Coronary Artery dissection diagnosis according to ICD-10 codes. Readmission was defined as the first admission to any hospital for any non-trauma diagnosis within 30 days of the index discharged alive. The primary outcome was 30 DRr, while secondary outcomes were readmission mortality rate, most common diagnoses for readmission, & resource utilization defined by total patient charge (TPC), & hospital cost (THC). Results: A total of 479 index hospitalization for SCAD; mean age of 54.4years (SD±14.6), female 74.8%, with an in-hospital mortality rate for index admission of 4.4% (21). 30-DRr was 7.7% (35). The mean age for readmitted patient was 53.8yrs (SD±17.8), female 73.3%, with an in-hospital mortality rate was 5.7% (n=2), which was not statistically significant compared to index mortality. The total in-hospital cost associated with readmission was $ 320,401 & TPC of $ 1,320,662. Conclusions: We observed 1 in 13 are readmitted within 30 days among patient with SCAD . SCAD patients are a vulnerable subset requiring additional outpatient care. Improved clinical care and management of SCAD with guideline-based therapeutics may help reduce readmission, mortality & cost.

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.

Spontaneous Coronary Artery Dissections: A Systematic Review.

Myocardial infarction with nonobstructive coronary artery disease due to spontaneous coronary artery dissection (SCAD) accounts for 5–8% of acute coronary syndrome (ACS) presentations. The demographic characteristics, risk factors, and management of patients with SCAD differ from those with atherosclerotic disease. The objective of this review is to provide a contemporary understanding of the epidemiology, pathophysiology, clinical presentation, and management of SCAD.

A Case Report on Spontaneous Coronary Artery Dissection Managed by Percutaeneous Coronary Intervention (PCI)

Background: Spontaneous coronary artery dissection (SCAD) is frequently underdiagnosed and often considered as a rare cause of acute coronary syndrome (ACS). Although it predominantly affects young women in the peripartum period, it can also occur in men. Most of the reported dissections have occurred in the left anterior descending coronary artery. The optimal treatment modalities are yet to be defined. Case Summary: A 50- year-old man who presented to us at National Institute of Cardio-Vascular Diseases (NICVD), Dhaka with an acute Non-ST-elevation myocardial infarction secondary to a spontaneous dissection of the Left anterior descending coronary artery. Due to ongoing chest pain, percutaneous coronary intervention (PCI) was done with drug eluting stent (DES) successfully, and the patient was discharged from the hospital on medical therapy. Conclusion: All clinicians should remain vigilant and aware of this condition, as patient outcomes and treatment guidelines differ substantially from conventional atherosclerotic ACS. Although initial conservative strategy is preferred strategy in SCAD management but timely intervention is warranted in selected cases. Bangladesh Heart Journal 2021; 36(2): 151-157

Acute Myocardial Infarction in a Healthy 57-Year-Old Female; A Case Report

Spontaneous coronary artery dissection (SCAD) commonly present as acute coronary syndrome in otherwise healthy population especially in women. SCAD is defined as dissection involving epicardial coronary arteries, not related to any trauma, or atherosclerosis process or any iatrogenic causes, resulting in intimal disruption and/or Intra-mural hematoma (IMH). SCAD is often misdiagnosed and therefore the treatment is delayed resulting in complications. This review will focus on a case presentation and the diagnosis and management of SCAD.

Abstract 14266: Management of Spontaneous Coronary Artery Dissection: Trends Over Time

Introduction: Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of ACS that preferentially impacts young women. Increasing evidence suggests that patients with SCAD do well with a conservative approach, as intramural hematoma frequently resolves with medical management and complications from PCI are common. Our objective is to describe changes in management of SCAD over time at the University of Pennsylvania Health System (UPHS). Methods: We conducted a retrospective cohort study among patients treated within UPHS from 2005-2019. We identified all patients in the electronic health record with SCAD using ICD-9 (414.12) and ICD-10 (I25.42) codes. Charts were manually reviewed and indexed by date of SCAD event. Time categories were calculated by tertiles of patients. Since the first tertile spanned 21 years, this category was subdivided. The most recent time period represents practice after the AHA Scientific Statement on SCAD was published. Cochran-Armitage trend tests compared trends over time. Results: We identified 140 patients with SCAD. In this cohort, 43% of patients treated from 1993-2005 were managed conservatively, compared to 89% of patients treated in 2018-2019, while 57% of patients treated from 1993-2005 were managed invasively, compared to 11% of patients treated in 2018-2019, p<0.001 for trend over time (Figure). Between 1993-2005 and 2018-2019, the use of DAPT increased from 40% to 80% (p<0.001 for trend) and use of statins increased from 60% to 85% (p=0.021 for trend). Beta blocker use remained stable (80% vs. 89%, p=0.401) and ACEi/ARB use varied considerably without a clear trend over time (p=0.553). Conclusions: The proportion of patients with SCAD managed conservatively has steadily increased since 2015. This trend corresponds to the increased understanding of clinical outcomes of this patient population. Medical treatment has changed over time and most patients are treated with DAPT, statins, and beta blockers.

Updates in Spontaneous Coronary Artery Dissection.

To review the epidemiology, pathogenesis, diagnosis using emerging imaging modalities, management strategy, and prevention of recurrent spontaneous coronary artery dissection (SCAD) and provide a more extensive review of the current data. SCAD generally affects women without conventional cardiovascular risk factors. Diagnosis and management of SCAD are challenging due to heterogeneity, undefined mechanisms, differing phenotypes, and a lack of strong clinical evidence. After reviewing the current evidence to date, we recommend conservative management, including cardiac rehabilitation for SCAD with low-risk features, while coronary revascularization should be considered in SCAD with high-risk features. Non-invasive imaging (e.g., coronary computed tomography angiography, cardiac magnetic resonance, myocardial perfusion imaging) should be considered in diagnosing specific SCAD phenotypes. The standard guideline-based medical therapy for acute coronary syndrome, in the absence of contraindications, should be considered along with appropriate SCAD phenotypes. Discharge counseling and follow-up using emerging imaging modalities should be based on individuals' profiles and approached on a case by case basis.

Spontaneous Coronary Artery Dissection Secondary to Rheumatological Diseases: A Comprehensive Review.

Spontaneous coronary artery dissection (SCAD) is a life-threatening condition and multiple conditions have been associated with this entity. This study aims to further investigate and characterize the association of the underlying rheumatological disease with SCAD. A comprehensive literature search on four databases was performed using different Medical Subject Headings (MeSH) and all articles on SCAD in association with rheumatological diseases were identified. The analysis was performed using the Statistical Package for Social Sciences (SPSS), v22 (IBM SPSS Statistics, Armonk, NY). Ten articles of SCAD secondary to rheumatological reasons were identified. The majority of presentations were associated with systemic lupus erythematosus (SLE). Most patients presented with a non-ST-elevation myocardial infarction (NSTEMI) involving the left main coronary vessel. The majority of them were successfully managed with stenting. Mortality was less than 20% with prompt identification and management of the SCAD. SLE was the most commonly reported rheumatological condition associated with SCAD. Prompt diagnosis and management of SCAD in such patients can be life-saving.

Spontaneous Coronary Artery Dissection: Diagnosis and Management.

Spontaneous coronary artery dissection (SCAD) is a non-iatrogenic and non-traumatic separation of the coronary arterial wall. While SCAD represents an important cause of myocardial infarction, optimal diagnostic and therapeutic options remain challenging. We sought to review recent studies and provide an update on diagnosis and management of SCAD. Coronary angiography is the first-line diagnostic modality for SCAD, with three angiographic features commonly observed in SCAD: type 1 (pathognomonic angiographic appearance with contrast staining of the arterial wall), type 2 (long coronary stenosis), and type 3 (focal tubular stenosis). In addition, adjunctive intracoronary imaging can aid in identifying coronary dissections. Conservative management with beta-blockers and aspirin remains the mainstay of therapy. However, patients with high-risk features and recurrent symptoms may require revascularization. Several techniques have been reported, such as long stents to seal the entire length of the dissection, stepwise stenting starting at the distal edge followed by proximal edge stenting, use of bioabsorbable stents, and cutting balloon angioplasty. Furthermore, cardiac rehabilitation appears to be safe and offers significant benefits for patients with SCAD. Coronary angiographic classification contributed to the increased recognition of SCAD in recent years. Selecting the most suitable and appropriate therapy based on accurate diagnosis is the cornerstone of management in SCAD. Further studies are needed to establish optimal treatment of SCAD depending on anatomical and/or clinical features.

Rare case of asymptomatic spontaneous coronary artery dissection

We present a case of a 46-year-old woman who presented to the emergency room after a syncopal episode. Most of her initial workup did not lead to any diagnosis. However, the transthoracic echocardiogram showed new onset left ventricular dysfunction. Further, cardiac evaluation showed a chronic coronary artery dissection in the proximal left anterior descending artery. Syncope was related to vasovagal event but rapid plasma reagin being positive led to the question of whether the coronary artery dissection was secondary to vasculitic manifestation of prior syphilis infection. More research is needed to answer this question and to find such an association.<Learning objective: Spontaneous coronary artery dissection (SCAD) is a rare disease of young adults that can present acutely as an acute coronary syndrome (ACS) with chest pain, as malignant ventricular arrhythmia, and even as sudden cardiac death. Our report is focused on evaluation and management of SCAD, more importantly to consider SCAD as a differential diagnosis in ACS in young patients, especially females. Our review also stresses the need for further research toward development of consensus on management of such patients.>

Spontaneous coronary artery dissection-A review.

Spontaneous coronary artery dissection (SCAD) is an infrequent and often missed diagnosis among patients presenting with acute coronary syndrome (ACS). Unfortunately, SCAD can result in significant morbidities such as myocardial ischemia and infarction, ventricular arrhythmias and sudden cardiac death. Lack of angiographic recognition from clinicians is a major factor of under-diagnosis. With the advent of new imaging modalities, particularly with intracoronary imaging, there has been improved diagnosis of SCAD. The aim of this paper is to review the epidemiology, etiology, presentation, diagnosis and management of SCAD.

A successful emergency management of spontaneous coronary artery dissection and review of the literature

Spontaneous coronary artery dissection (SCAD) is a rare and lethal myocardial ischemic event, which usually causes acute coronary syndrome and sudden death. Emergency management of SCAD includes medical treatment, percutaneous coronary interventions, and coronary artery bypass grafting. Here, we report 1 case of 37-year-old young woman who was found to have a mid-distal SCAD of the left anterior descending artery, taking conservative management decision. In another case of a 50-year-old woman who was found to have a proximal-middle spiral SCAD of the right coronary artery, she underwent coronary angioplasty. After 6 months later at follow-up, 2 patients remained stable without symptom and in recovery of the left ventricular function; angiogram showed the SCAD healed.

The role of intravascular ultrasound guidance in the treatment of intramural hematoma probably caused by spontaneous coronary artery dissection in a young woman with acute anterior myocardial infarction

Spontaneous coronary artery dissection (SCAD) is known to be a rare but fatal cause of acute coronary syndromes. It is more frequent in young women, particularly in the peripartum period. Intravascular ultrasound (IVUS) has an important role in the diagnosis and management of SCAD. Intramural hematoma that occurs between adventitial and media layer of the vessel wall may occlude the true lumen. IVUS can identify intimal tears, the extension of intramural hematoma and show the adequate compression of intramural hematoma after percutaneous coronary intervention. We present a case of intramural hematoma caused by SCAD in a young woman presenting with acute anterior myocardial infarction, and the role of IVUS in the diagnosis and management of SCAD.

Successful Management of Spontaneous Dissection with Spasm in both Coronary Arteries

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. SCAD frequently occurs in young women during the peripartal period. There are few reports of SCAD associated with vasospasm. We report a case of a 36-year-old man who presented at our institution with SCAD with spasm. He presented with continuous chest pain for 1 hour. Initial EKG showed pathologic Q wave and ST elevation in lead II, III, and aVF. Emergent coronary angiography (CAG) revealed diffuse spastic narrowing of the left anterior descending coronary artery (LAD) and right coronary artery. On follow-up CAG, spontaneous type B dissection of the proximal LAD extending to the left main and middle LAD were detected. We decided to treat with medical therapy because he had no chest pain. Three days later, patient complained of severe chest pain. Emergency CAG revealed dissection in the left main to middle LAD and proximal left circumflex artery (LCx) with poor distal flow and spasm in the distal LAD. We performed percutaneous coronary intervention for SCAD in the LAD. The follow-up CAG performed 6 months later showed patent LAD stents. This case illustrates the successful management of SCAD that developed in both the culprit and non-culprit arteries of acute myocardial infarction associated with vasospasm.

Spontaneous Coronary Artery Dissection: Case Report and Review of Literature

Spontaneous coronary artery dissection (SCAD) is a deadly cause of myocardial infarction (MI) that mainly affects otherwise healthy, young females. We examine the case of a young female who presented with chest pain. She developed ST elevations in anterolateral leads mimicking ST elevation MI. Cardiac catheterization was done and showed a proximal left anterior descending (LAD) dissection. The patient underwent primary percutaneous transluminal coronary angioplasty with four paclitaxel-eluting coronary stents placed in the LAD. Diagnosis and management of SCAD have remained a challenge and no guidelines have yet been proposed due to the rarity and uncertain etiology of this condition. We review the medical literature on spontaneous coronary artery dissection and discuss its pathogenesis.