Spontaneous Coronary Artery Dissection Patients Research Articles

A review of the risk and precipitating factors for spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) accounts for 1%-4% of cases of acute coronary syndrome (ACS). SCAD is caused by separation occurring within or between any of the three tunics of the coronary artery wall. This leads to intramural hematoma and/or formation of false lumen in the artery, which leads to ischemic changes or infarction of the myocardium. The incidence of SCAD is higher in women than in men, with a ratio of approximately 9:1. It is estimated that SCAD is responsible for 35% of ACS cases in women under the age of 60. The high frequency is particularly observed during pregnancy and in the peripartum period (first week). Traditional risk factors are rare in patients with SCAD, except for hypertension. Patients diagnosed with SCAD have different combinations of risk factors compared with patients who have atherosclerotic changes in their coronary arteries. We presented the most common so-called "non-traditional" risk factors associated with SCAD patients. In the literature, there are few diseases frequently associated with SCAD, and they are identified as predisposing factors. The predominant cause is fibromuscular dysplasia, followed by inherited connective tissue disorders, systemic inflammatory diseases, pregnancy, use of sex hormones or steroids, use of cocaine or amphetamines, thyroid disorders, migraine, and tinnitus. In recent years, the genetic predisposition for SCAD is also recognized as a predisposing factor. The precipitating factors are also different in women (emotional stress) compared with those in men (physical stress). Women experiencing SCAD frequently describe symptoms of anxiety and depression. These conditions could increase shear stress on the arterial wall and dissection of the coronary artery wall. Despite the advancement of SCAD, we can find significant differences in the clinical presentation between women and men. When evaluating patients with chest pain or other ACS symptoms who have a low cardiovascular risk, particularly female patients, it is important to consider the possibility of ACS due to SCAD, particularly in conditions often associated with SCAD. This will increase the recognition of SCAD and the timely treatment of affected patients.

Hospital Outcomes of Spontaneous Coronary Artery Dissection With Concurrent Ventricular Arrhythmias

BackgroundWhile patients with spontaneous coronary artery dissection (SCAD) occasionally present with concurrent ventricular arrhythmias (VA), the impact of VA on in-hospital outcomes in the United States (US) is not well-established. This study aims to analyze in-hospital outcomes of patients with SCAD and concurrent VA and to determine the factors associated with VA occurrence in this high-risk population in the US. MethodsUsing the Nationwide Readmissions Database, our study included patients age 18 years or older who had SCAD between 2017 and 2020. We categorized the cohort into 2 groups depending on the presence of VA during hospitalization. In-hospital outcomes were assessed between SCAD patients with VA and those without. Weighted analysis was performed. We analyzed the independent factors associated with VA occurring among SCAD patients through univariable and multivariable analyses. ResultsEight hundred seventy-seven SCAD patients were included in the study: 118 (13.5%) with VA and 759 (86.6%) without. SCAD patients with concurrent VA were associated with higher rates of early mortality (10.2% vs 2.0%; P < .01), prolonged index hospital stay (≥7 days) (33.1% vs 11.7%; P < .01), and non-home discharge (21.2% vs 5.9%; P < .01). The length of hospital stay was longer in the SCAD with concurrent VA group (7.39 days vs 3.58 days; P < .01), and the median cumulative cost of hospitalization was also higher in this group ($31,451 vs $13,802; P < .01). SCAD patients with concurrent VA had increased in-hospital adverse events: acute heart failure, cardiac arrest, cardiogenic shock, cerebral infarction, pulmonary edema, and acute kidney injury. In multivariable analysis, the independent factors associated with VA occurrence among SCAD patients were chronic liver disease (aOR, 3.42; 95% CI, 1.43-8.20; P < .01) and heart failure (aOR, 5.63; 95% CI, 3.36-9.42; P < .01). ConclusionsConcurrence of VA among SCAD patients was associated with poorer in-hospital outcomes. Heart failure and chronic liver disease were the independent factors associated with VA occurrence in SCAD patients.

Abstract 13027: Hospital Outcomes and Predictors of Spontaneous Coronary Artery Dissection With Concurrent Ventricular Arrhythmias

Background: While spontaneous coronary artery dissection (SCAD) patients can present with ventricular arrhythmias (VAs), the in-hospital outcomes among these patients are not well-established. Objective: This study aimed to analyze the in-hospital outcomes of patients with SCAD and concurrent VAs, and to determine the predictors of VAs occurrence in this population. Methods: Using the Nationwide Readmissions Database, our study included patients aged 18 years or older who had SCAD between 2017 and 2020. We categorized the cohort into two groups depending on the presence of VAs during hospitalization. The in-hospital outcomes were assessed between two groups. Through multivariable analysis, we further analyzed the predictors of VAs occurrence among SCAD patients. Results: Our study included 160 (13.45%) SCAD patients with concurrent VAs and 1,030 (86.55%) SCAD patients without concurrent VAs between 2017 and 2020. SCAD patients with concurrent VA were associated with higher rates of early mortality (11.88% vs. 2.04%, p&lt;0.01), prolonged index hospital stay (≥7 days) (31.25% vs. 12.82%, p&lt;0.01), and non-home discharge (21.88% vs. 6.50%, p&lt;0.01). The length of hospital stay was longer in the SCAD with concurrent VAs group (6.93 days vs. 3.73 days, p&lt;0.01), and the median cumulative cost of hospitalization was also higher in this group ($31,450 vs. $14,664, p&lt;0.01). SCAD with concurrent VAs patients also had poorer in-hospital adverse events. In multivariable analysis, the independent predictors for VAs occurrence among SCAD patients were chronic liver disease (aOR: 2.18; 95% CI: 1.15- 4.12, p=0.02) and heart failure (aOR: 3.40; 95%CI: 2.30- 5.02, p&lt;0.01). Conclusion: Ventricular arrhythmias among SCAD patients were associated with poorer in-hospital outcomes. Heart failure and chronic liver disease were the predictors of VAs in SCAD patients. This highlights the importance of closely monitor and aggressive VAs management among these high-risk patients.

Abstract 12535: Spontaneous Coronary Artery Dissection in Women: A New Role for Autoimmunity?

Introduction: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of myocardial infarction (MI) in women, with a still unclear pathophysiology. Autoantibodies targeting angiotensin-II receptor type 1 (AT1R) and endothelin-1 receptor type A (ETAR) (AT1R-AAs and ETAR-AAs, respectively) lead to endothelial dysfunction and have already been associated with aortic dissection. Hypothesis: We hypothesized that titers of AT1R-AAs and ETAR-AAs are higher in patients with SCAD compared to controls. Methods: Our case-control study was conducted at Padua University Hospital between January 2022 and June 2022. Female patients diagnosed at coronary angiography with MI and SCAD were consecutively enrolled. Ten women with SCAD and 20 age-matched controls (10 women with ST-elevation MI (STEMI) and 10 healthy women) were included. Serum levels for AT1R-AAs and ETAR-AAs were determined for each participant. Absolute autoantibody titers and seropositivity prevalence were compared between SCAD patients, STEMI patients, and healthy women. Seropositivity was defined according to the threshold value suggested by the manufacturer (&gt;10 U/mL). Results: Six out of 10 (60%) women with MI and SCAD were seropositive for AT1R-AAs and ETAR-AAs. In contrast, only one (10%) healthy woman and one (10%) STEMI patient were seropositive for AT1R-AAs (p=0.03 and p=0.03, respectively). One STEMI patient was seropositive for ETAR-AAs, while none of the healthy women was found to be seropositive (p=0.03 and p=0.01, respectively). The median autoantibody titer was significantly higher in SCAD patients than in healthy women (p=0.01 for AT1R-AAs; p=0.02 for ETAR-AAs) and STEMI patients (p&lt;0.001 for AT1R-AAs; p=0.002 for ETAR-AAs). Conclusions: AT1R-AAs and ETAR-AAs seropositivity is significantly higher in SCAD women than in healthy women or female patients with STEMI. Our findings suggest a possible role for AT1R-AAs and ETAR-AAs in the pathophysiology of SCAD in women with MI.

Abstract 19053: Peripheral Eosinophil Count is Associated With Left Ventricular Systolic Dysfunction During Spontaneous Coronary Artery Dissection

Background: Spontaneous coronary artery dissection (SCAD) is an underdiagnosed condition disproportionally affecting young women, particularly during the peripartum period and/or in the presence of systemic inflammatory and autoimmune diseases. Tissue-level studies have demonstrated inflammatory infiltrates with adventitial or peri-adventitial eosinophilia at the site of SCAD lesions. Less is known regarding how systemic markers of immune activation associate with cardiac dysfunction in SCAD. Hypotheses: Higher eosinophil count and Neutrophil-to-Lymphocyte Ratio (NLR) associate with LV systolic dysfunction in SCAD patients. Methods: In individuals diagnosed with SCAD who underwent CBC with differential and echocardiography within the same presenting hospital encounter, we performed age- and sex-adjusted logistic regressions with eosinophil count (% of differential) and NLR (% of differential) as primary exposures and LVEF&lt;55% as the dichotomous endpoint. A p&lt;0.05 was considered statistically significant. We explored associations of neutrophil, lymphocyte, monocyte, and basophil counts with LVEF in secondary analyses. Results: In SCAD patients with complete CBC and LVEF data (N=36; mean age 49.9 years at diagnosis, 28 female), peripheral eosinophil count was associated with significantly higher odds of systolic dysfunction [OR of LVEF&lt;55% per every 1% higher eosinophil count = 1.87; 95% CI 1.04, 3.36; p=0.04]. NLR ratio was not associated with LV systolic dysfunction (OR 1.05; 95% CI 0.94, 1.18; p=0.35) nor were other circulating leukocyte fractions. Conclusion: Peripheral eosinophil count, but not other circulating leukocyte counts, was associated with LV systolic dysfunction as measured by LVEF &lt;55%. These findings provide complementary support to pathology-based evidence of eosinophilia observed in SCAD lesions and require confirmation in future longitudinal studies of changes in LV function following SCAD events.

Abstract 11638: Physician Attitudes Toward Beta Blocker and Antiplatelet Therapy in Spontaneous Coronary Artery Dissection Patients

Background: Spontaneous Coronary Artery Dissection (SCAD) primarily affects younger women and is a cause of acute coronary syndrome for which medical management guidelines and clinical trial data are lacking. Our study assessed physician attitudes toward beta blocker (BB) and antiplatelet therapy (APT) in SCAD. Methods: We conducted an online survey among 165 physicians who treat SCAD. Data were collected about their demographics, BB and APT prescribing practices in hypothetical SCAD patients each with one key difference from the base case, and willingness to randomize patients to BB or no BB and to dual APT [DAPT] (12 months of aspirin and P2Y12 inhibitor, then only aspirin) or single APT [SAPT] (3 months of aspirin, then no APT). Results were analyzed with descriptive statistics and chi-squared test. Results (Table): Of the respondents, 163 (99%) were cardiologists, and 64 (39%) were women. When considering BB at discharge, 88% of physicians would prescribe BB in the base case of an otherwise healthy 49-year-old woman with SCAD, with higher likelihood of prescribing BB in a patient with hypertension or ejection fraction (EF) &lt; 50%. Most physicians (95%) were willing to randomize the base case to BB or no BB. Respondents expressed uncertainty about the benefit of BB use, particularly in patients with normal blood pressure or with EF &gt; 50%. When considering APT at discharge, 38% of physicians would prescribe DAPT, 46% would prescribe SAPT, and 16% would prescribe no APT in the base case. Most physicians (92%) were willing to randomize the base case to the DAPT or SAPT strategies. Physicians expressed concern about inadequate and excessive APT, indicating a range of opinions. Conclusion: Most physicians would prescribe BB and APT at discharge after SCAD, with the type of APT varying widely. Nearly all were willing to randomize patients to BB or no BB and to DAPT or SAPT. Our results suggest clinical equipoise exists for BB and APT use in SCAD and point to the need for clinical trial data.

Spontaneous coronary artery dissection-associated takotsubo syndrome: A systematic review of case reports.

Spontaneous coronary artery dissection (SCAD) is underdiagnosed and requires comprehensive angiographic findings. Few SCAD occurrences have a comparable clinical appearance as takotsubo syndrome (TTS) or exist simultaneously, making it challenging for clinicians to treat and manage. Case reports lack consolidated data. We examined SCAD-TTS case reports. To conduct a systematic review of available case reports on SCAD in order to investigate its potential association with TTS. SCAD-associated TTS case reports were reviewed after thoroughly screening PubMed, EMBASE, Scopus, and Google Scholar databases till January 2023. Case reports described demographics, comorbidities, imaging, management, and results. Twelve articles about 20 female patients were analyzed. 30% of patients (n = 6, > 60 years) were elderly (mean age 56.2 ± 9.07 years, range 36-70 years). Canada has 9 cases, United States 3, Australia 3, Sweden 2, Japan, Denmark, and France 1. Only 5 reports identified emotional stressors in these cases while 4 reports showed physical triggers for TTS. Nine had hypertension, 2 had hyperlipidemia, and 1 had prediabetes. 5 patients (25%) smoked. 10 (50%) troponin-positive myocardial infarction patients reported chest discomfort. 11 (55%) of 20 instances had TTS/SCAD. 12 (60%) of 20 patients exhibited ST elevation and 3 (15%) had T wave inversion on electrocardiogram. 19/20 patients had elevated troponin. 9 (45%) of 20 people had apical akinesis with TTS ballooning on cardiac imaging. All 20 exhibited echocardiographic wall motion abnormalities. 19 (95%) of 20 coronary angiography cases had SCAD. 10 of 19 SCAD patients had left anterior descending, 2 diagonal, and 2 left circumflex coronary artery involvement. 7 of 20 patients had left ventricular ejection fraction (LVEF) data. LVEF averaged 38.78 ± 7.35%. 5 (25%) of the 20 cases underwent dual antiplatelet therapy. Three (15%) of 20 cases experienced occasional ectopic ventricular complexes, Mobitz ll AV block, and paroxysmal atrial fibrillation. All 20 cases recovered and survived. Given the clinical similarities and challenges in detecting TTS and SCAD, this subset needs more research to raise awareness and reduce morbidity.

Spontaneous coronary artery dissection in women with acute myocardial infarction: is there a new role for autoimmunity?

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction in women and has an unclear pathophysiology. Autoantibodies (AAs) targeting angiotensin-II receptor type 1 (AT1R) and endothelin-1 receptor type A (ETAR) have known detrimental effects on endothelial function. We investigated the prevalence of these AAs in SCAD-affected female patients. Female patients diagnosed at coronary angiography with myocardial infarction and SCAD were consecutively enrolled. Autoantibodies targeting angiotensin-II receptor type 1 and ETAR-AA titres and seropositivity prevalence were compared between SCAD patients, ST-elevation myocardial infarction (STEMI) patients, and healthy women. Ten women with SCAD and 20 age-matched controls (10 women with STEMI and 10 healthy women) were included. Six out of 10 (60%) women with myocardial infarction and SCAD were seropositive for AT1R-AAs and ETAR-AAs. In contrast, only one (10%) healthy woman and one (10%) STEMI patient were seropositive for AT1R-AAs (P = 0.03 and P = 0.03, respectively). One STEMI patient was seropositive for ETAR-AAs, while none of the healthy women was found to be seropositive (P = 0.03 and P = 0.01, respectively). The median AA titre was significantly higher in SCAD patients than in healthy women (P = 0.01 for AT1R-AAs; P = 0.02 for ETAR-AAs) and STEMI patients (P < 0.001 for AT1R-AAs; P = 0.002 for ETAR-AAs). Autoantibodies targeting angiotensin-II receptor type 1 and ETAR-AA seropositivity is significantly higher in SCAD women with myocardial infarction than in healthy women or female patients with STEMI. Our findings, corroborated by previous data in the literature and biological plausibility, suggest a possible role for AT1R-AAs and ETAR-AAs in the pathophysiology of SCAD in women with acute myocardial infarction and should warrant further studies with larger sample sizes.

Derivation and Validation of Spontaneous Coronary Artery Dissection Prediction Score in Patients With Myocardial Infarction

Spontaneous coronary artery dissection (SCAD) is an important cause of acute myocardial infarction (AMI); however, the prevalence of SCAD and its predictors in AMI are unknown. We sought to derive and validate a simple score that can help predict SCAD in patients with AMI. We analyzed the Nationwide Readmissions Database and created a risk score for SCAD in patients with an index hospitalization for AMI. We used a multivariate logistic regression analysis to determine the independent predictors of SCAD, and each was assigned points proportional to its regression coefficient. Among 1,155,164 patients with AMI, 8,630 (0.75%) had SCAD. Based on the derivation cohort, the independent predictors of SCAD were fibromuscular dysplasia (odds ratio [OR] 67.0, 95% confidence interval [CI] 42.0 to 107.9, p <0.01), Marfan or Ehlers-Danlos syndrome (OR 4.7, 95% CI 1.7 to 12.5, p <0.01), polycystic ovarian syndrome (OR 5.4, 95% CI 3.0 to 9.8, p <0.01), female gender (OR 1.99, 95% CI 1.9 to 2.1, p <0.01), and aortic aneurysm (OR 1.41, 95% CI 1.1 to 1.7, p <0.01). The SCAD risk score included fibromuscular dysplasia (5 points), Marfan or Ehlers-Danlos syndrome (2 points), polycystic ovarian syndrome (2 points), female gender (1 point), and aortic aneurysm (1 point). The C-statistics of the score were 0.58 (derivation cohort) and 0.61 (validation cohort). In conclusion, the SCAD score is an easy bedside clinical tool that can help clinicians identify patients with AMI who are at risk for SCAD.

Stress Cardiomyopathy and Spontaneous Coronary Artery Dissection: Linked or Overlooked?

This case series aimed to explore the association between spontaneous coronary artery dissection (SCAD) and stress cardiomyopathy (SCM), which are conditions that share similar features and can present as acute coronary syndrome. Both can be precipitated by emotional and/or physical stressors. Diagnosis is with coronary angiogram for SCAD, and echocardiogram for SCM. It is less common for people to have features of both. The overlap syndrome becomes evident if the territory of the involved coronary artery is incongruent with the left ventricular (LV) regional wall motion abnormality (RWMA). This single-centre case series identified cases with possible overlap of stress cardiomyopathy and SCAD. Patients were searched for individually, using an electronic health database (Health Connect South) through discharge summaries over a 2-year period. Cases with a likely diagnosis of both stress cardiomyopathy and SCAD were identified. The echocardiographic abnormalities included LV apical hypo/akinesis in all cases. In most cases, SCAD was confined to the mid and/or distal left anterior descending (LAD) artery. Two cases involved SCAD in multiple coronary arteries. This case series was able to clearly see the coexistence of an overlap syndrome in some cases. However, the association between the two conditions is under-recognised. It is proposed that an invasive coronary angiogram or computerised tomography coronary angiogram be actively reviewed to diagnose SCAD in patients with SCM, and early and repeat imaging in patients with SCAD is essential to identify SCM.

Combined spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS): a case series

BackgroundSpontaneous Coronary Artery Dissection (SCAD) and Takotsubo Syndrome (TTS) are two different entities with several shared risk factors, but their management is different. They can co-exist in patients with chest pain which affects their management. We present two cases of combined SCAD and TTS in patients presented with chest pain.Case presentationCase 1: 80F admitted with typical chest pain and dynamic ECG changes on the background of known anxiety/depression and social stresses. Her coronary angiogram showed SCAD affecting distal LAD. The left ventriculogram (LV gram) showed apical ballooning consistent with Takotsubo Syndrome (TTS). Patient was discharged on aspirin as well as angiotensin receptor blocker (ARB).Case 2: 60F admitted with typical chest pain in the setting of emotional trauma on the background of known cardiovascular risk factors. She was found to have ST elevation in inferior leads with no reciprocal changes. Subsequently, coronary angiogram showed SCAD affecting mid-left anterior descending artery (LAD) with normal distal wrap around LAD. Her LV gram showed apical ballooning consistent with TTS. However, transthoracic echocardiogram showed akinetic left ventricular apex. She was discharged on aspirin as well as an ACE inhibitor and warfarin to prevent LV thrombus.ConclusionsSCAD and TTS can co-exist in patients with chest pain. It is important to identify SCAD in patients with TTS as it may affect their short as well as long-term management.

Prevalence of Anxiety, Depression, and Distress in SCAD and Non-SCAD AMI Patients: A Comparative Study.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute myocardial infarction (AMI), particularly in younger women without classic cardiac risk factors. Spontaneous coronary artery dissection is considered to be particularly stressful; however, few studies have quantified SCAD survivor stress levels. This study compared anxiety, depression, and distress levels in SCAD and non-SCAD AMI patients. A sample of 162 AMI (35 [22%] SCAD) patients was recruited from hospitals and via social media, in Australia and the United States. All had had their AMI in the past 6 mo. Participants completed an online questionnaire comprising the Generalized Anxiety Disorder-2 (GAD2), Patient Health Questionnaire-2 (PHQ2), Kessler-6 (K6), and Cardiac Distress Inventory (CDI). T-tests, χ 2 tests, Mann-Whitney tests, and analysis of covariance were used to compare SCAD and non-SCAD samples. Logistic regression was used to identify the unique predictors of anxiety, depression, and distress, controlling for relevant confounders. Patients with SCAD were more commonly female and significantly younger than non-SCAD patients. Patients with SCAD scored significantly higher on the GAD2, PHQ2, K6, and CDI and a significantly larger proportion was classified as anxious, depressed, or distressed using these instruments. In logistic regression, together with mental health history, having had a SCAD-AMI predicted anxiety, depression, and distress, after controlling for female sex, younger age, and other confounding variables. This study supports the view that anxiety, depression, and distress are more common after SCAD-AMI than after traditional AMI. These findings highlight the psychosocial impacts of SCAD and suggest that psychological support should be an important component of cardiac rehabilitation for these patients.

Spontaneous coronary artery dissection: review, case report and analysis of COVID-19-related cases.

Spontaneous coronary artery dissection (SCAD) accounts for 1-4% of all acute coronary syndromes (ACS). Since the first description in 1931, our understanding of the disease has evolved; however, its pathophysiology and management are still a matter of debate. SCAD typically occurs in a middle-aged woman with no or few traditional cardiovascular risk factors. Two hypotheses have been proposed to explain the pathophysiology depending on the primary event: an intimal tear in the "inside-out" hypothesis and a spontaneous hemorrhage from the vasa vasorum in the "outside-in" hypothesis. Etiology appears to be multifactorial: different predisposing and precipitating factors have been identified. Coronary angiography is the gold standard for the diagnosis of SCAD. Current recommendations on the treatment of SCAD patients are based on expert opinions: a conservative strategy is preferred in hemodynamically stable SCAD patients, while urgent revascularization should be considered in hemodynamically unstable patients. Eleven cases of SCAD in COVID-19 patients have already been described: although the exact pathophysiological mechanism remains unclear, COVID-19-related SCAD is considered a combination of significant systemic inflammatory response and localized vascular inflammation. We present a literature review of SCAD, and we report an unpublished case of SCAD in a COVID-19 patient.

Treatment strategy for spontaneous coronary artery dissection based on anatomical characteristics

ObjectivesTo compare the clinical and angiographic characteristics of high-risk and low-risk spontaneous coronary artery dissection (SCAD) patients to determine the optimal treatment strategy.BackgroundSCAD is a rare and emerging cause of acute coronary syndrome and sudden cardiac death, especially in young female patients. However, the indication of percutaneous coronary intervention (PCI) in patients with SCAD remains elusive.MethodsWe evaluated the clinical and angiographic characteristics of all SCAD patients admitted to our center from 2012 to 2020. The outcomes of the high-risk and low-risk SCAD patients according to the location of the lesion segment with dissection or intramural hematoma were compared. Further analyses were performed to evaluate the vessel healing or residual dissection in the patients receiving the follow-up angiography.ResultsA total of 81 SCAD patients were enrolled in the present study, in which 38 patients were categorized as high-risk group, defined as involvement of the left main artery or proximal segment of any main coronary artery. PCI was the more common treatment approach in the high-risk group (68.4%), while conservative treatment was more common in the low-risk group (62.8%). The incidence of major adverse cardiac events, defined as cardiac death, myocardial infarction, unstable angina pectoris, severe arrhythmias, or heat failure, within 1 year follow-up was similar between the two groups. 57 patients (70.4%) received the follow-up angiography after 1 year. The high- and low-risk groups had a similar rate of vessel healing among the PCI treatment patients. However, more patients achieved spontaneous healing in the low-risk group than the high-risk group among the conservative treatment patients (86.4% vs. 33.3%, p < 0.05).ConclusionsConservative management remains the recommended treatment strategy for the low-risk SCAD patients. PCI could be considered in high-risk SCAD patients with favorable clinical outcomes and vessel healing. Characterization of lesion anatomy may be an important indicator for treatment decision.

Multimodality Imaging Approach to Spontaneous Coronary Artery Dissection

Spontaneous Coronary Artery Dissection (SCAD) refers to the spontaneous separation of the layers of the vessel wall caused by intramural hemorrhage, with or without an intimal tear. The "typical" SCAD patient is a middle-aged woman with few traditional cardiovascular risk factors, and it's frequently associated with pregnancy. Because of its low incidence, its pathophysiology is not fully understood. SCAD presents as an acute coronary syndrome, with chest pain, dyspnea, syncope, or heartbeat, even if diagnosis and clinical handling are different: coronary angiography is currently the main tool to diagnose SCAD; however, in doubtful cases, the use of both invasive and noninvasive cardiovascular imaging methods such as intravascular ultrasound or optical coherence tomography may be necessary. This paper aims to review the current state of knowledge on SCAD to address its demographic features, clinical characteristics, management, and outcomes, focusing on diagnostic algorithms and main multimodality imaging techniques.

220 MANAGING CARDIAC ARREST SECONDARY TO SPONTANEOUS CORONARY ARTERY DISSECTION: SHOULD WE ROUTINELY CONSIDER ICD IMPLANTATION?

Abstract Introduction Cardiac arrest secondary to a spontaneous coronary artery dissection (SCAD) represents a challenging scenario. It deserves specific considerations due to the dramatic presentation and the need for secondary sudden cardiac death prevention. Methods We collected clinical data of four women admitted during the last two years in the Coronary Care Unit of Parma University Hospital, whose presentation of SCAD were cardiac arrest due to ventricular fibrillation. Results Three patients survived the acute phases. One patient, being considered at high risk of SCAD recurrence, received a subcutaneous implantable cardioverter-defibrillator (S-ICD). Acute management of cardiac arrest related to SCAD deserves specific considerations. Our case series illustrates the importance of prompt resuscitation manoeuvres and early defibrillation. We propose a flow chart of management of cardiac arrest in patient with suspect of SCAD. Evaluating risk of SCAD recurrence and sudden cardiac death The management of SCAD patients complicated by malignant ventricular arrhythmias and cardiac arrest is challenging. Looking at published registries, it appears that SCAD patients are more likely to suffer from ventricular arrythmia or sudden cardiac death than non-SCAD MI patients. The risk-benefit ratio of ICD implantation in these patients remain uncertain . Evaluation of scar burden with CMR can help stratify the global arrhythmic risk, especially as extensive myocardial scar with a residual impaired LVEF increases the risk of future arrhythmic events. In our series, only one patient underwent S-ICD implantation, and the decision was mainly driven by the finding of underlying arteriopathy affecting other vascular territories, suggesting a potentially higher rate of SCAD recurrence. For this particular subset of patients, we propose an algorithm that combines predisposing factors and myocardia injury quantification data that could be useful for the estimate of the risk of malignant arrythmias, as well as the risk of recurrence of SCAD, but needs to be validated in larger case studies. Conclusions The acute management of cardiac arrest related to SCAD deserves specific consideration. The residual myocardial damage, predisposing and precipitants factors should be evaluated in order to estimate the SCAD recurrence and sudden cardiac death risks.

Characteristics and outcomes of percutaneous coronary interventions in patients with spontaneous coronary artery dissection. A study from the administrative minimum data set of the Spanish National Health System.

Coronary revascularization in patients with spontaneous coronary artery dissection (SCAD) is challenging. Indications and results of percutaneous coronary interventions (PCI) in SCAD patients are not well established. To assess indications and results of PCI in SCAD. The minimum basic data set of the Spanish National Health System (years 2016-2019) was used to identify 804 episodes of acute myocardial infarction (AMI) and SCAD, with a crude in-hospital mortality rate of 3%. Of these, 368 (46.8%) patients were revascularized with PCI during admission whereas 436 (54.2%) were managed conservatively. Revascularization and in-hospital mortality rates both declined over the study period (p for trend both < 0.05). SCAD patients treated with PCI were older, more frequently male, and had higher frequency of diabetes, ST-segment elevation AMI and cardiogenic shock, compared to patients managed conservatively. The crude in-hospital mortality rate was higher in patients treated with PCI (4.9% vs. 1.4%; p = 0.004). However, after adjusting by propensity score (223 pairs) the in-hospital mortality rate was similar in the two groups (Adj OR: 1.21; 95%CI: 0.30-1.57; p = 0.76). Readmissions at 30-days were higher in patients managed conservatively (7.1 vs. 1.6%, p < 0.001) and this difference was maintained after propensity score adjustment (Adj average treatment effect: 2% vs. 12.2%; OR: 0.15; 95%CI: 0.04-0.45; p < 0.001). Revascularization is frequently used in unselected patients with AMI and SCAD but its use is declining. Patients with SCAD treated with PCI have a higher in-hospital mortality but this appears to be explained by their adverse baseline clinical characteristics.

Spontaneous coronary artery dissection and ST-segment elevation myocardial infarction: Does clinical presentation matter?

BackgroundSome patients with spontaneous coronary artery dissection (SCAD) present as ST-segment-elevation myocardial infarction (STEMI). This study evaluates the characteristics, management and outcomes of SCAD patients presenting as STEMI compared to non-ST-segment elevation myocardial infarction (NSTEMI). MethodsWe analysed data from consecutive patients included in the prospective Spanish Registry on SCAD. All coronary angiograms were centrally reviewed. All adverse events were adjudicated by an independent Clinical Events Committee. ResultsBetween June 2015 to December 2020, 389 patients were included. Forty-two percent presented with STEMI and 56% with NSTEMI. STEMI patients showed a worse distal flow (TIMI flow 0–1 38% vs 19%, p < 0.001) and more severe (% diameter stenosis 85 ± 18 vs 75 ± 21, p < 0.001) and longer (42 ± 23 mm vs 35 ± 24 mm, p = 0.006) lesions. Patients with STEMI were more frequently treated with percutaneous coronary intervention (PCI) (31% vs 16%, p < 0.001) and developed more frequently left ventricular systolic dysfunction (21% vs 8%, p < 0.001). No differences were found in combined major adverse events during admission (7% vs 5%, p = 0.463), but in-hospital reinfarctions (5% vs 1.4%, p = 0.039) and cardiogenic shock (2.6% vs 0%, p = 0.019) were more frequently seen in the STEMI group. At late follow-up (median 29 months) no differences were found in the incidence of major adverse cardiac and cerebrovascular events (13% vs 13%, p-value = 0.882) between groups. ConclusionsPatients with SCAD and STEMI had a worse angiographic profile and were more frequently referred to PCI compared to NSTEMI patients. Despite these disparities, both short and long-term prognosis were similar in STEMI and NSTEMI SCAD patients.

Abstract 15281: Patient and System-Related Delays in Presentation and Invasive Coronary Angiography in Patients Presenting With Acute Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection: A Report of the ISCAD Registry

Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome especially in young patients. Factors associated with delays in presentation and care delivery are not well understood. Methods: We used data from the iSCAD Registry which is a prospective multicenter US registry of patients with SCAD. Early vs. delayed hospital presentation (&lt; 24 vs. ≥ 24 hours), and early vs. delayed coronary angiography (time from hospital presentation to coronary angiography &lt; 24 vs. ≥ 24 hours) for SCAD patients with AMI were assessed. Patient characteristics, and in-hospital events were compared between the two groups. Factors associated with delayed presentation and angiography were explored using multivariable logistic regression. Results: A total of 346 SCAD (294 white, 52 non-white) patients presented with STEMI (34%) or NSTEMI; 57 had a delayed presentation to the hospital after symptoms onset. No significant factors were identified for delays in seeking care. However, white race was less likely to have delayed invasive coronary angiography (multivariable OR=0.38; 95% CI 0.19 to 0.76; p=0.0059). Patients undergoing delayed angiography were also more likely to be medically managed (91.7% vs. 69.8%, p=0.0008), but less likely to receive dual antiplatelet therapy (57.0% vs. 73.1%, p=0.007). In-hospital outcomes were similar between the two groups. Conclusion: In this study, no patient-related variables were identified that predicted a delay in presentation with AMI secondary to SCAD. On the other hand, non-white race was associated with delays in performing invasive coronary angiography. Further investigation is required to determine the factors contributing to this potential disparity.

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 &amp; its impact healthcare utilization in the United States. Methods: Using the 2017 &amp; 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, &amp; resource utilization defined by total patient charge (TPC), &amp; 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 &amp; 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 &amp; cost.