2. SPONTANEOUS CORONARY ARTERY DISSECTION
• An epicardial coronary artery dissection that is not associated with
atherosclerosis or trauma and not iatrogenic.
Circulation. 2018;137:e523–e557
3. PREVALENCE
• The true prevalence of SCAD remains uncertain, primarily because it is an
underdiagnosed condition.
• SCAD most commonly occurs in patients with few or no traditional
cardiovascular risk factors.
• SCAD may be a cause of up to 1% to 4% of ACS cases overall.
• Occurs overwhelmingly in women(80-90%) and cause of up to 35% of MIs in
women ≤50 years of age
• Prevalance in pregnancy is 1.8% but most common cause of MI (43%) among
patients who are pregnant or postpartum.
Am J Cardiol. 2015;116:66–73.
10. DIAGNOSIS
• Accurate diagnosis of SCAD in the early stages of ACS presentation is important
because management and investigation are different from those for
atherosclerotic forms of coronary artery disease.
• The suspicion for SCAD is typically instigated by clinical presenting features such
as patient demographics, especially young age, female sex, and few or no
conventional cardiovascular risk factors.
• Once SCAD is suspected, coronary angiography should be performed as early
as feasible, especially in the setting of ST-segment–elevation MI
13. IMAGING FOR EXTRACORONARY ABNORMALITIES
Extracoronary abnormalities in spontaneous coronary artery dissection including renal
(A and D) and femoral (B) fibromuscular dysplasia, carotid and vertebrobasilar
aneurysms and tortuosity (C and F) and a localised iliac dissection (E).
14. MANAGEMENT
• There substantial evidence that the majority of SCAD will first stabilize and then
heal completely over time if managed conservatively
• Revascularization in patients with SCAD is very challenging due to the presence of
an underlying disrupted and friable coronary vessel wall. This is widely reported to
lead to worse outcomes for PCI than in atherosclerotic coronary disease.
• Revascularization is not mandated in haemodynamically stable patients with
maintained distal flow in the culprit coronary and without demonstrable ongoing
ischaemia.
• As the majority of cases failing a conservative management strategy occur early
during follow-up, prolonged inpatient monitoring (5 days) in conservatively
managed SCAD is suggested.
18. MEDICAL MANAGEMENT
• Thrombolysis: Thrombolysis is therefore contraindicated for the acute management of
SCAD.
• Antiplatelet: Patients who undergo stenting should receive dual antiplatelet therapy for 12
months and prolonged or lifelong monotherapy In patients managed conservatively, acute
dual antiplatelet therapy is indicated however the optimal duration of dual and subsequent
monotherapy remains unknown.
• ACEI/ BB/MRA: Left Ventricular Dysfunction
• Statins: Statins are reserved for patients with conventional indications for treatment
independent of their SCAD event.
19. PREGNANCY-ASSOCIATED SCAD
• The majority of pregnancy-associated SCADs occur in the first 4 weeks after
delivery, but SCAD has been reported during virtually all stages of pregnancy.
• Despite the special situation presented by pregnancy, the principles of SCAD
management are largely the same as for non–pregnancy-associated SCAD
with careful planning of labour and delivery.
• Early and careful angiography to avoid iatrogenic dissection and to confirm
the diagnosis and aiming for conservative management if there is no evidence
of ongoing ischemia or infarction, hemodynamic instability, or particularly high-
risk anatomy.
21. SCAD CLINICAL OUTCOMES & RECURRENCE
• MACE rate at 3 years was 19.9%, primarily in the form of MI; recurrent SCAD
was seen in 10.4%
• Patients with hypertension at baseline were twice as likely to have a recurrence
(HR 2.46; 95% CI 1.23-4.93)
• Beta-blocker use was associated with greatly reduced risk of recurrent tear (HR
0.36; 95% CI 0.18-0.73)
327 troponin-positive ACS patients with non atherosclerotic SCAD treated at a
single institution, 2012-2016.
Saw J, et al. J Am Coll Cardiol. 2017;70:1148–1158.
Implications: Hypertension and lack of beta-blocker therapy may be contributors to
the high rate of recurrence of SCAD after initial treatment.
22.
23. KEY POINTS
The strong female predisposition and association with pregnancy suggest a role for
female sex-hormones in the pathogenesis of SCAD but the mechanism remains
unknown.
Spontaneous coronary artery dissection is frequently associated with extra-
coronary arteriopathies including FMD.
SCAD should be considered in differential diagnosis of ACS presentation in low risk
patients
Most SCAD can be diagnosed by coronary angiography and a working knowledge
of the typical angiographic findings is key.
Intracoronary imaging with OCT appears safe and should be considered where
there is diagnostic uncertainty.
24. KEY POINTS
• Coronary revascularization is associated with an increased risk of complications
and adverse outcomes compared with atherosclerotic coronary disease.
• Conservatively (without revascularization) managed SCAD usually heals
completely over a few months.
• Where flow is maintained and in the absence of ongoing ischaemia or infarction,
a conservative approach should be considered followed by a period of inpatient
observation.
• Research is needed to clarify the optimal PCI strategy in cases where
revascularization is necessary
• P-spontaneous coronary artery dissection should be managed by a
multidisciplinary team with individualized cardiovascular and obstetric
management.
25. KEY POINTS
• Although the prognosis following SCAD appears good, recurrent SCAD is well recognized.
• Assessment for extra-coronary arteriopathies is advised in SCAD-survivors.
• Cardiac rehabilitation should be considered in SCAD patients and a return to full-activity
with an avoidance of extreme or isometric exercise encouraged.
• Recurrent chest pain after SCAD is common and requires careful assessment and
management.
