Spontaneous Coronary Artery Dissection Patients Research Articles

Spontaneous Coronary Artery Dissection (SCAD) with cardiac arrest at presentation: a subanalysis from the DISCO registry

Abstract Introduction Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI), which primarily affects young women without traditional cardiovascular risk factors, often presenting as sudden cardiac death. This study aims to investigate the prevalence, characteristics, predictors, and outcomes of cardiac arrest in SCAD patients. Methods The DISCO IT/SPA registry, an international retrospective multicenter study, enrolled 375 SCAD patients from 26 centers in Italy and Spain. Patients were categorized based on the presence or absence of cardiac arrest at admission. Data on demographics, clinical presentation, treatment, angiographic findings, and outcomes were collected. Angiograms were independently reviewed, and outcomes included major adverse cardiovascular events (MACE) and in-hospital bleeding. Results Among 375 SCAD patients, 20 (5.3%) presented with cardiac arrest. Both groups were similar in age, gender distribution, and conventional risk factors, except for a lower prevalence of dyslipidemia in the cardiac arrest group. ST-segment elevation myocardial infarction (STEMI) presentation and angiographic type 2b were independent predictors of cardiac arrest. Revascularization was more frequent in the cardiac arrest group. In-hospital outcomes, except for longer hospitalization, did not differ. On follow-up (average 21 months), MACE rates were similar between groups. Conclusions Cardiac arrest is a notable complication in SCAD, mostly presenting with ventricular fibrillation. The prognosis of SCAD patients presenting with cardiac arrest did not differ from those without, reporting a similar rate of events both in-hospital and during long-term follow-up. STEMI presentation and angiographic type 2b were identified as independent predictors of cardiac arrest in SCAD.

7531 Spontaneous Coronary Artery Dissection Induced Diabetic Ketoacidosis In A Young Female: A Rare Complication Of Ketosis In A Priorly Non-Insulin Dependent Diabetic

Abstract Disclosure: F. farhat: None. P. Gonzalez: None. A.B. Ravin: None. H. Akhlaq: None. M. hossain: None. K. chalasani: None. S.W. Holland: None. R. Ong: None. J. Cheng: None. Introduction: Spontaneous Coronary Artery Dissection (SCAD) is a poorly understood and underdiagnosed condition that puts healthy young women at risk of Myocardial infarction (MI) and potential death. It occurs when a tear develops in a coronary artery. SCAD can have an atypical presentation especially in diabetic and young females; Diabetic ketoacidosis (DKA) is an uncommon, yet potentially fatal complication and can be the primary presentation in SCAD. We present a case of SCAD complicated by DKA in a non insulin dependent diabetic (NIDD).Case presentation: A 19 year old female with a past medical history of NIDDM presented to the Emergency Department with chest pain. She had troponemia and ECG revealed ST elevations. Patient was found in DKA initially. Insulin drip was started with DKA resolution in 24 hours. Hemoglobin A1c was 12.4% with negative antibody workup. Her course was complicated by SCAD found upon cardiac catheterization with unsuccessful recanalization; she was not a surgical candidate given late presentation and therefore, an intra aortic balloon pump was placed. Subsequently, she developed pericarditis and left ventricular thrombus. Discussion: SCAD is a rare condition, often presenting with acute MI and cardiogenic shock. MI may be complicated with DKA. One proposed mechanism for that is the activation of ketogenic pathways caused by excess catecholamines and cortisol; this increases physiologic stress on the body resulting in increased ketogenesis, lipolysis and free radicals causing further myocardial injury. DKA precipitated by MI increases the mortality rate to nearly 85% since the myocardium is denied glucose uptake. Signs and symptoms of SCAD are similar to MI symptoms including: chest tightness, shortness of breath and sweating. MI and SCAD can be differentiated by cardiac catheterization or by specialized contrasted CT scans. 20% of SCAD patients will experience a second episode within 5 years. Avoiding emotional stress, exercising regularly, following a healthy diet and controlling chronic conditions can help lower the risk for SCAD. Medical management is often preferred. Invasive treatments like coronary stenting or cardiac bypass may be needed if there is a complete blockage in the vessel, clinical instability or ongoing chest pain. Conclusion: SCAD is an important cause of MI in young females and can present initially as DKA in diabetics. For clinicians facing such rare cases, it is worth maintaining a broad approach to the diagnosis and treatment of these patients. The causes of SCAD remain fully unclear and genetic relations are still under investigation. Since DM type I and SCAD occur in young people, it is extremely important for clinicians to consider SCAD in the differential while managing DKA. Presentation: 6/3/2024

Diagnosis and management of spontaneous coronary artery dissection: Two cases and a review of the literature

Introduction and importance: Spontaneous coronary artery dissection (SCAD) is a rare but potentially fatal condition, often underdiagnosed despite its significance in acute coronary syndrome (ACS). The true prevalence remains uncertain due to diagnostic challenges. Identifying SCAD cases is crucial for reducing mortality and morbidity, especially considering the recurrence risk. The authors present two cases highlighting the importance of multimodality imaging in diagnosing and managing SCAD. Case presentation: Case 1: A 53-year-old man with a history of brain aneurysm presented with chest pain and shortness of breath. Despite negative EKGs and stress tests, coronary computed tomography angiography (CCTA) revealed non-obstructive dissection flaps. Medical management improved his condition. Case 2: A 55-year-old woman with no significant medical history experienced recurrent chest pain. Initial tests were negative, but CCTA revealed SCAD. Further screening uncovered undiagnosed fibromuscular dysplasia. Clinical discussion: SCAD poses diagnostic challenges, often mimicking other cardiac conditions. Traditional tests may yield negative results, necessitating advanced imaging techniques like CCTA. Recognizing SCAD’s association with connective tissue disorders (CTD) is vital for comprehensive patient care. The authors’ cases emphasize the importance of a systematic approach to diagnosing chest pain, including noninvasive modalities and considering underlying etiologies. Conclusion: SCAD diagnosis requires a high index of suspicion, especially when traditional cardiac tests are inconclusive. Beyond treatment, patients should undergo further evaluation for CTDs, particularly in those with minimal risk factors for atherosclerosis. Increased awareness and a multimodal diagnostic approach are crucial for timely intervention and improved outcomes in SCAD patients. Learning objectives: The authors aim to increase awareness regarding different clinical presentations of SCAD to decrease the risk of missed or late diagnosis. The authors’ case series also signifies the multimodal imaging approach’s role in evaluating chest pain. Upon diagnosis of SCAD, it is imperative to go beyond treatment and implement a reverse algorithmic strategy to discover any underlying causes and risk factors for SCAD predisposition.

Characteristics of Patients with Spontaneous Coronary Artery Dissection Presenting with Sudden Cardiac Arrest in the United States and the Potential Role of Implantable Cardioverter Defibrillator Therapy.

Spontaneous coronary artery dissection (SCAD) is a disease entity that often occurs in young, healthy women and can cause life-threatening ventricular arrhythmias and sudden cardiac arrest. However, the characteristics and outcomes of SCAD with cardiac arrest are not well characterized. This study investigated the baseline characteristics of SCAD patients with cardiac arrest using the National Inpatient Sample (NIS) database between 2016 and 2020. In addition, we also sought to determine the potential impact that implantable cardioverter defibrillator (ICD) therapy had on morbidity and mortality in SCAD patients presenting with cardiac arrest. Our findings showed that the SCAD with cardiac arrest population had significantly higher comorbidities, including cardiac arrhythmias, congestive heart failure, pulmonary circulation disorders, liver diseases, solid tumors, coagulopathy, fluid disorders, chronic kidney disease (CKD), anemia secondary to deficiency, psychosis, neurological disorders, carotid artery disease, atrial fibrillation, ventricular arrhythmias (ventricular tachycardia (VT), ventricular fibrillation (VF)), and acute myocardial infarction (AMI), compared to the SCAD without cardiac arrest population. Likewise, for SCAD patients who did not have an ICD in place, we found increasing age, fluid and electrolyte disorders, uncomplicated diabetes, neurological disorders, peripheral vascular disease, pulmonary circulatory disorders, cardiac arrhythmias, and congestive heart failure to be associated with greater mortality. SCAD patients with certain comorbidities (e.g., pulmonary diseases, liver diseases, cancers, coagulopathy, and CKD) who presented with AMI or congestive heart failure should be monitored closely for ventricular arrhythmias as they have a higher chance of progressing to cardiac arrest. ICD therapy can be considered for these patients, but data on the success of this treatment option are limited, and more research needs to be performed to determine whether the benefits of this outweigh the risks.

Clinical Outcomes of Cardiogenic Shock Due to Spontaneous Coronary Artery Dissection Versus Cardiogenic Shock Due to Coronary Artery Disease.

Spontaneous coronary artery dissection (SCAD) can be treated conservatively. However, some SCAD patients can develop cardiogenic shock (CS). We evaluated the outcomes of SCAD-related CS using data from a national population-based cohort study from January 1, 2016, to December 30, 2019. In our study of 32,640 patients with SCAD, about 10.6% of patients presented with CS. We found that SCAD patients with CS had higher mortality and greater complications including use of mechanical circulatory devices, arrhythmias, respiratory support, and acute heart failure compared to those without CS. When comparing CS due to SCAD with that due to coronary artery disease, we found that although mortality rates were similar, those with CS due to SCAD were associated with higher risk of use of mechanical circulatory support, major bleeding, blood transfusion, and respiratory failure.

Talin-1 variants associated with spontaneous coronary artery dissection (SCAD) highlight how even subtle changes in multi-functional scaffold proteins can manifest in disease.

Variants of talin-1 (TLN1) have recently been linked with spontaneous coronary artery dissection (SCAD) a condition where a tear can form in the wall of a heart artery necessitating immediate medical care. One talin-1 variant, A2013T, has an extensive familial pedigree of SCAD, which led to the screening for, and identification of, further talin-1 variants in SCAD patients. Here we evaluated these variants with commonly used pathogenicity prediction tools and found it challenging to reliably classify SCAD-associated variants, even A2013T where the evidence of a causal role is strong. Using biochemical and cell biological methods, we show that SCAD-associated variants in talin-1, which would typically be classified as non-pathogenic, still cause a measurable impact on protein structure and cell behaviour, including cell movement and wound healing capacity. Together, this indicates that even subtle variants in central mechanosensitive adapter proteins, can give rise to significant health impacts at the individual level, suggesting the need for a possible re-evaluation of the scoring criteria for pathogenicity prediction for talin variants.

The genetics of spontaneous coronary artery dissection: a scoping review.

Spontaneous coronary artery dissection (SCAD) is a multifactorial process that involves predisposing factors and precipitating stressors. Genetic abnormality has been implicated to play a mechanistic role in the development of SCAD. This systematic review aims to summarize the current evidence concerning the link between SCAD and genetic abnormalities. We reviewed original studies published until May 2023 that reported SCAD patients with a genetic mutation by searching PubMed, Embase Ovid, and Google Scholar. Registries, cohort studies, and case reports were included if a definitive SCAD diagnosis was reported, and the genetic analysis was performed. Exclusion criteria included editorials, reviews, letters or commentaries, animal studies, meeting papers, and studies from which we were unable to extract data. Data were extracted from published reports. A total of 595 studies were screened and 55 studies were identified. Among 116 SCAD patients with genetic abnormalities, 20% had mutations in the COL gene, 13.70% TLN1 gene, and 8.42% TSR1 gene. Mutations affecting the genes encoding COL and TLN1 were most frequently reported (20 and 13.7%, respectively). Interestingly, 15 genes of this collection were also reported in patients with thoracic aortic diseases as well. The genetic commonality between fibromuscular dysplasia (FMD) and SCAD was also included. In this review, the inherited conditions and reported genes of undetermined significance from case reports associated with SCAD are collected. A brief description of the encoded protein and the clinical features associated with pathologic genes is provided. Current data suggested that the diagnostic yield of genetic studies for patients with SCAD would be low and routine genetic screening of such patients with no clinical features indicative of associated disorders remains debatable. This review can be used as a guide for clinicians to recognize inherited syndromic and nonsyndromic disorders associated with SCAD.

Racial Disparities in Outcomes of Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of ST-segment elevation myocardial infarction (STEMI), predominantly affecting women. Because primary percutaneous coronary intervention (PPCI) is reserved for a select group of patients, vulnerable and minority patients may suffer delays in appropriate management and adverse outcomes. We examined racial differences in the outcomes for SCAD patients undergoing PPCI for STEMI. Records of patients ≥18 years old who underwent PPCI for SCAD-related STEMI between 2016 and 2020 were identified from the National Inpatient Sample database. Clinical, socioeconomic, and hospital characteristics were compared between non-White and White patients. Weighted multivariate analysis assessed the association of race with inpatient mortality, length of stay (LOS), and hospitalization costs. The total weighted estimate of SCAD-STEMI patients undergoing PPCI was 4945, constituting 25% non-White patients. Non-White patients were younger (56 vs. 60.7 years, p<0.001), had a higher prevalence of diabetes, acute renal failure, and obesity, and were more likely to be uninsured and be in the lowest income group. Inpatient mortality (7.7% vs. 8.4%, p=0.74) and hospitalization costs ($34213 vs. $31858, p=0.27) were similar for non-White and White patients, and adjusted analysis did not show any association between patients’ race and inpatient mortality (odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.32-1.13; p=0.11) or hospitalization costs (β: 215; 95% CI: -4193 to 4623; p>0.90). Similarly, there was no association between patients’ race and LOS (incident rate ratio: 1.20; 95% CI: 1.00-1.45; p=0.054]. Weighted multivariate analysis showed that age; clinical comorbidities such as diabetes, acute renal failure, valvular dysfunction, and obesity; low-income status; and hospitalization in the Western region were associated with adverse outcomes. In conclusion, our study does not show any differences in inpatient mortality, length of stay, and hospitalization costs between non-White and White patients undergoing PPCI for SCAD-related STEMI.

SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD) WITH CARDIAC ARREST AT PRESENTATION: A SUBANALYSIS FROM THE DISCO REGISTRY

Abstract Introduction Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI), which primarily affects young women without traditional cardiovascular risk factors, often presenting as sudden cardiac death. This study aims to investigate the prevalence, characteristics, predictors, and outcomes of cardiac arrest in SCAD patients. Methods The DISCO IT/SPA registry, an international retrospective multicenter study, enrolled 375 SCAD patients from 26 centers in Italy and Spain. Patients were categorized based on the presence or absence of cardiac arrest at admission. Data on demographics, clinical presentation, treatment, angiographic findings, and outcomes were collected. Angiograms were independently reviewed, and outcomes included major adverse cardiovascular events (MACE) and in–hospital bleeding. Results Among 375 SCAD patients, 20 (5.3%) presented with cardiac arrest. Both groups were similar in age, gender distribution, and conventional risk factors, except for a lower prevalence of dyslipidemia in the cardiac arrest group. ST–segment elevation myocardial infarction (STEMI) presentation and angiographic type 2b were independent predictors of cardiac arrest. Revascularization was more frequent in the cardiac arrest group. In–hospital outcomes, except for longer hospitalization, did not differ. On follow–up (average 21 months), MACE rates were similar between groups. Conclusions Cardiac arrest is a notable complication in SCAD, mostly presenting with ventricular fibrillation. The prognosis of SCAD patients presenting with cardiac arrest did not differ from those without, reporting a similar rate of events both in–hospital and during long–term follow–up. STEMI presentation and angiographic type 2b were identified as independent predictors of cardiac arrest in SCAD.

CARDIOGENIC SHOCK DUE TO SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract Spontaneous coronary artery dissection (SCAD) is an important but rare cause of myocardial infarction (MI) in young adults, particularly women. Current guidelines recommend conservative treatment, given the low angiographic success and the high complication rate of percutaneous coronary intervention. However, in SCAD patients presenting with STEMI or cardiogenic shock the needs of urgent revascularization is critical and PCI may be life threatening. We present a case report occurs in our Hospital of a 42–year–old young woman without cardiovascular risk factors or notable comorbidities which was admitted to our emergency department for typical chest pain. At admission the patient had a cardiovascular arrest from refractory ventricular fibrillation who was rescued according to ACLS protocol. After resumption of ROSC, EKG showed anterolateral STEMI (FIGURE 1). Bedside echocardiography showed a severe reduction in systolic function (EF 30%) due to akinesia of the apex, septum and antero–lateral wall, with absence of noticeable valvulopathy, pericardial effusion or pathological findings in the right heart sections. Therefore the patient underwent to Cath–lab for emergent coronary angiography that showed ostial DA subocclusion with SCAD type 2a on middle tract (Figure 2) IVUS (intravascular ultrasound) imaging confirmed the diagnosis of SCAD, served to guided angioplasty on the LM–DA axis and to confirme optimal stent placement (FIGURE 3). Subsequently, the course was complicated by a double shock component: first SCAI C cardiogenic shock that requested or IMPELLA CP implantation and second haemorrhagic shock due to profound hepatic bleeding because of traumatic injury caused by prolonged resuscitation maneuvers. Mechanical ventricular support ensured haemodynamic stability to allow percutaneous embolisation of the hepatic arteries and patient stabilization. Once the haemorrhagic focus was treated and cardiac function recovered, the patient‘s condition gradually improved leading to a rapid weaning of haemodynamic and respiratory support. No neurological sequelae were observed after the acute phase. Conclusions 1) Urgent revascularization in patients with SCAD and high clinical instability is life threatening. IVUS imaging is crucial to confirm the diagnosis and guide the procedure. 2) The IMPELLA support in this case provided short–term haemodynamic support in a double component of shock.

Females with a History of Spontaneous Coronary Artery Dissection Exhibit Greater Pressor Responses to Isometric Handgrip and Post-exercise Ischemia Compared to Healthy Females

Background: Spontaneous coronary artery dissection (SCAD) causes acute coronary syndrome via the sudden separation between the coronary arterial wall layers and/or hematoma. The SCAD patient population is &gt;80% female who typically have few or no traditional cardiovascular disease risk factors (e.g., obesity, hypertension). Risk of a recurrent SCAD is reported as high as 19% at 3 years after an initial SCAD. Mechanisms underlying SCAD (re)occurrence are unknown. Common triggers for SCAD include sympathoexcitatory stimuli, including heavy exercise and intense Valsalva-like activities. This study tested the hypothesis that SCAD patients exhibit greater neurocardiovascular responses (e.g., blood pressure, heart rate, muscle sympathetic nerve activity) to isometric handgrip and post-exercise ischemia compared to healthy females. Methods: Eight females with a history of SCAD (age: 56±6 yrs, BMI: 28±4 kg/m2) and 6 age- and BMI-matched healthy female controls (CON, age: 55±8 yrs, BMI: 26±5 kg/m2) participated. Continuous blood pressure (finger photoplethysmography) and heart rate (3-lead ECG) were measured during rest (1 minute), isometric handgrip at 30% maximal voluntary contraction (2 minutes), and post-exercise ischemia at 220 mmHg (2 minutes) to isolate the skeletal muscle metaboreflex. Muscle sympathetic nerve activity (MSNA, peroneal microneurography) was measured in a subset of participants (5 SCAD/4 CON). Data are presented as an absolute change from rest (mean±SD). Two-way independent t-tests were used for statistical analyses. Results: Resting mean blood pressure (SCAD: 96±8 vs CON: 91±9 mmHg, p=0.354), heart rate (SCAD: 56±11 vs CON: 59±10 bpm, p=0.666), and MSNA (SCAD: 50±19 vs CON: 43±32 bursts/100 heartbeats, p=0.697) were not different between groups. Relative to healthy controls, SCAD patients elicited greater increases in mean blood pressure during isometric handgrip (SCAD: Δ9±3 vs CON: Δ4±4 mmHg, p=0.034) and post-exercise ischemia (SCAD: Δ7±4 vs CON: Δ3±3 mmHg, p=0.046). There were no group differences regarding heart rate responses during isometric handgrip (SCAD: Δ3±4 vs CON: Δ4±4 bpm, p=0.359) and post-exercise ischemia (SCAD: Δ3±4 vs CON: Δ2±3 bpm, p=0.861). Responses in MSNA during isometric handgrip (SCAD: Δ12±8 vs CON: Δ9±8 bursts/100 heartbeats, p=0.536) and post-exercise ischemia (SCAD: Δ11±2 vs CON: Δ13±10 bursts/100 heartbeats, p=0.713) also were not different between groups. Conclusion: These preliminary data suggest that compared to healthy females, female patients who experienced a SCAD exhibit greater pressor, but not chronotropic or sympathetic, responses to isometric handgrip and post-exercise ischemia. Exaggerated pressor responses to these perturbations may be a potential risk factor for SCAD (re)occurrence. NIH K23 HL155506, NIH T32 DK07352, NIH K01 HL148144, NIH UL1 TR0022377, and AHA 898649. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Two case reports of spontaneous coronary dissection

Spontaneous coronary artery dissection (SCAD) has nowadays been described as a non-negligible etiology of acute coronary syndromes (ACS). Its prevalence approximates 3% in most cohorts. It mainly affects women in the young to middle-aged range. Individuals with SCAD typically exhibit fewer conventional cardiovascular risk factors associated with ischemic heart disease compared to those with atherosclerotic coronary artery disease. Nevertheless, some SCAD patients may present with risk factors such as hypertension, smoking, and dyslipidemia, although their direct contribution to SCAD risk remains uncertain. We present two cases of spontaneous coronary dissection to explore its pathogenesis, diagnosis, and treatment options. Learning objectives · Recognize spontaneous coronary artery dissection as the possible cause of ACS in females even with cardiovascular risk factors. Learn the importance of angiographic control after a conservative therapy that may lead to a more invasive approach.

Coronary Artery Tortuosity and Spontaneous Coronary Artery Dissection: Association With Echocardiography and Global Longitudinal Strain, Fibromuscular Dysplasia, and Outcomes

The etiology and significance of coronary artery tortuosity (TCA) among patients with spontaneous coronary artery dissection (SCAD) are unknown. The aim of this prospective imaging cohort study was to report echocardiographic findings and evaluate whether TCA correlates with cardiac anatomy and function among patients with SCAD. Comorbidities including fibromuscular dysplasia (FMD) and outcomes were also assessed. TCA was determined on coronary angiography performed during the diagnosis of SCAD, and cardiac structure and function were evaluated using prospective comprehensive echocardiography. Among 116 patients with SCAD, the mean age at echocardiography was 50.8±8.8years, a median of 10.9months after SCAD. Sixty-two patients (53.4%) had FMD, 41 (35.3%) had histories of hypertension, and 17 (14.8%) were hypertensive during echocardiography. Most patients (n=78 [69%]) had normal left ventricular geometry with normal median ejection fraction (61%; interquartile range, 56% to 64%) and normal global longitudinal strain (-22.2%; interquartile range, -24.0% to -19.9%). Fifteen patients (13.4%) had diastolic dysfunction that was associated with hypertension at the time of echocardiography. Patients with TCA (n=96 [82.8%]) were older (mean age, 52.1±8.0 vs 44.7±9.9years; P<.001) with a higher prevalence of FMD (59.4% vs 25%, P=.007) but a similar prevalence of hypertension (35% vs 35%, P>.99) compared with patients without TCA. Across the age range (31.5 to 66.9years), each decade of age was associated with an approximately 0.89-unit increase in coronary tortuosity score (P<.0001). Echocardiographic parameters were not significantly different between the two groups. Median follow-up duration was 4.4years (95% CI, 3.8 to 5.2years). The Kaplan-Meier 3-year SCAD recurrence rate was 9.4% (95% CI, 3.7% to 14.8%). There were no deaths. The majority of patients with SCAD had normal or near normal echocardiographic results, including global longitudinal strain, with no differences according to TCA. However, patients with SCAD with TCA were older, with a higher prevalence of FMD.

Spontaneous Coronary Artery Dissection with Cardiogenic Shock in the United States.

Spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic separation of the epicardial coronary artery walls that creates a false lumen. SCAD poses a difficult challenge in management, as decisions regarding revascularization and medical management seem to be tailored to the individual patient. We evaluated and compared outcomes based on cardiogenic shock in patients with SCAD utilizing Nationwide Readmissions Database (NRD) between January 1, 2016, to December 30, 2020. We utilized the NRD 2016-2019 to carry out this study. We evaluated demographics (e.g., age, gender), conventional risk factors, comorbidities present on the index admission, and in-hospital outcomes using their specific ICD-10-CM codes. The primary outcomes were In-hospital mortality and 30-day readmission, and the secondary outcome was to compare the complications in SCAD patient with cardiogenic shock (CS) compared to those without CS. We analyzed 2473 individuals with SCAD, 2199 of these individuals did not have cardiogenic shock whereas 274 of these individuals did have cardiogenic shock. When comparing SCAD with cardiogenic shock to SCAD without cardiogenic shock, there was a statistically significant increased odds ratio (OR) for death (propensity matched OR 24.93 (7.49-83.05), use of mechanical circulatory support (propensity matched OR 15.30 (6.87-34.04), ventricular tachycardia (propensity matched OR 4.45 (1.92-10.34), utilization of blood transfusions (propensity matched OR 3.82 (1.86-7.87), acute kidney injury (propensity matched OR 4.02 (1.45-11.13), need for mechanical ventilation (propensity matched OR 8.87 (3.53-22.31), and respiratory failure (propensity matched OR 4.95 (1.83-13.41)))))))). There was no statistically significant difference in 30-day readmission rates between the two groups. SCAD is a unique condition that can lead to many complications. In our analysis, we showed that SCAD associated with cardiogenic shock compared to SCAD not associated with cardiogenic shock results in greater odds of complications including death, use of mechanical circulatory support, need for blood transfusions, ventricular tachycardia, acute kidney injury, use of mechanical ventilation, and respiratory failure. SCAD with cardiogenic shock represents a significantly critical clinical scenario that requires a multi-disciplinary approach to prevent the many potential complications associated with this disease process.

Successful healing of aneurysmal false lumen using a second-generation drug-eluting stent in spontaneous coronary artery dissection: a case report

BackgroundAccording to 2023 ESC Guideline, conservative medical management is generally recommended for the treatment of spontaneous coronary artery dissection (SCAD) except for patients with signs of ongoing myocardial ischemia. However, in some cases, invasive treatment (coronary artery bypass graft surgery or percutaneous coronary intervention (PCI)) is performed because of the progression of aneurysm in SCAD. Although there is no established strategy for the management of coronary aneurysm in SCAD, we report a case of successful healing of aneurysmal false lumen (AFL) using a second-generation drug-eluting stent (DES) in SCAD.Case presentationA 44-year-old woman without any cardiovascular risk factors was transferred to our hospital due to inferior myocardial infarction. Coronary angiography (CAG) showed multiple SCADs in the coronary artery. We performed PCI to the distal right coronary artery (RCA) because the RCA showed severe stenosis (99%) with bradycardia. Six days after the first PCI, SCAD relapsed in the mid left anterior descending artery (LAD). Furthermore, AFL was observed by intravascular ultrasound imaging. To avoid enlargement of the AFL and progression of the dissection toward the proximal site of the LAD, we performed PCI to the mid LAD to seal the entry tear of the dissection using a second-generation DES. CAG revealed that the AFL in the mid LAD completely diminished at 1 year after PCI.ConclusionsThe implantation of a second-generation DES might be one of therapeutic options for sealing AFL in SCAD patients.

Spontaneous Coronary Artery Dissection (SCAD) from an Interventionalist Perspective.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly among women < 50years of age. Here, we aim to review the pathogenesis of SCAD, discuss SCAD as an initial manifestation of systemic arterial disease, and highlight invasive strategies as well as unique challenges in the care of women with SCAD. A paradigm shift has occurred in the care of SCAD patients in the past decade as recommendations for conservative management have become widespread. Invasive interventions are reserved for patients with hemodynamic compromise or active ischemia due to increased periprocedural complications and failure rates. Certain patient populations have been identified for larger territory infarcts and proximal disease including patients with known connective tissue disease, premenopausal women, and patients with pregnancy-associated SCAD (P-SCAD). Current recommended management of SCAD is conservative. Despite a growing awareness of SCAD and its known association with systemic arteriopathies in women, evidence-based data remains scarce. Future studies focused on identifying genetic factors, optimal medical therapy after SCAD, and techniques to minimize interventional complications are needed.

Early Effects of the COVID-19 Pandemic on Patients in a Virtual Multicenter Spontaneous Coronary Artery Dissection (SCAD) Registry

BackgroundThe COVID-19 pandemic effects among patients with a history of spontaneous coronary artery dissection (SCAD), a cause of acute coronary syndrome associated with emotional and physical stress, are unknown. MethodsFor this cross-sectional cohort study, participants of the Mayo Clinic “Virtual” Multicenter SCAD Registry were surveyed about the COVID-19 pandemic. ResultsAmong 1352 participants, 727 (53.8%) completed surveys between June 2, 2021 and September 29, 2021. The majority of respondents (96.7%) were female, with a mean age of 54.9 ± 9.4 years. At the time of completing the survey, which was early in the pandemic, 91 respondents (12.6%) reported having prior COVID-19 symptoms, with < 1% experiencing hospitalization (n = 4) or cardiac complications (n = 6). A total of 14% had ≥ moderate anxiety symptoms, per the General Anxiety Disorder-7 item survey, and 11.8% had ≥ moderate depressive symptoms, per the Patient Health Questionnaire-9 item. Higher stress scores on the Likert scale were correlated with pandemic-related reduction in work hours and/or pay and/or unemployment (P = 0.013), remote work and/or change of job (P < 0.001), and loss of insurance and/or medical coverage (P = 0.025). A higher anxiety level, as measured on the Likert scale, was correlated with pandemic-related remote work and/or change of job (P = 0.007) and loss of insurance and/or medical coverage (P = 0.008). Since the start of the pandemic, 54% of respondents reported having at least monthly chest pain. Chest pain and COVID symptoms were each associated with higher scores on the General Anxiety Disorder-7 item survey and the Patient Health Questionnaire-9 item. ConclusionsEarly in the pandemic, COVID-19 symptoms, hospitalization, and cardiac complications were uncommon among SCAD patients. The burden of anxiety and depressive symptoms was minimal to mild, similar to that in prior reports. Likert-scale measures of stress and anxiety were higher among persons with work and/or pay reduction and/or unemployment, remote work and/or change of job, and loss of insurance and/or medical coverage. Over half of respondents reported experiencing chest pain, which was correlated with depressive and anxiety symptoms, highlighting an overarching clinical need.

Spontaneous coronary artery dissection and fibromuscular dysplasia: insights into recent developments.

Spontaneous coronary artery dissection (SCAD), an uncommon cause of acute coronary syndrome, continues to be a poorly understood disease predominantly affecting females. It is characterized by an abrupt separation in the coronary arterial wall due to intramural bleeding. Fibromuscular dysplasia (FMD) is a non-atherosclerotic arteriopathy manifesting in medium and small-sized arteries. It is a concomitant disease found among SCAD patients. In some studies, FMD prevalence in SCAD patients ranges between 25%-86%, which can be explained through varying screening techniques or modalities. The potential association has been elucidated in some studies; notably, not only has a genetic link been recently delineated between SCAD and FMD, but there is data to suggest that FMD not only can predispose to SCAD but can also be a potential predictor of its recurrence. However, a clear-cut correlation between the two has still not been established due to conflicting reports in the literature. To further dive into its pathology, it is crucial to highlight the importance of systematic screening in SCAD in order to identify associated risk factors and to be used as a method of FMD detection in such patients. Together, the two pathologies pose unique challenges in understanding its pathophysiology, diagnosis and management, as there is no clear evidence of a definitive treatment plan for patients with SCAD and FMD. A potentially beneficial modality of management is physical exercise, which is currently understudied in the long-term approach to treatment for patients with concomitant SCAD and FMD. Limited research in this field brings disadvantages to the understanding of the association between these two diseases, in order to give rise to better management recommendations. This mini-review aims to highlight the recent developments in the association between SCAD and FMD, its potential genetic association and some insights in screening, diagnosis, and management.

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.