Multiple spontaneous coronary artery dissections: a multidisciplinary challenge in diagnosis and treatment

33-Year-Old Woman With Postpartum Acute Shortness of Breath

Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS). Although it is difficult to differentiate SCAD from other causes of ACS based on the clinical presentation, some patient characteristics can aid the clinician in considering SCAD as a diagnosis. Namely, SCAD is far more common in women, especially in the peripartum period, and patients often do not have typical risk factors associated with atherosclerosis-related myocardial infarction. Furthermore, there is an association with FMD, migraine, and inherited connective tissue disorders. The primary pathophysiologic disturbance is the separation of layers of the coronary artery, either by hemorrhage from the vasa vasorum and formation of an intramural hematoma or by blood entering the vessel wall through an endothelial disruption thus creating a false lumen. The most common presentations are myocardial infarction, cardiogenic shock, and ventricular arrhythmias, while the most common presenting symptom is chest pain. The gold standard in diagnostics is coronary angiography. Angiography findings can be classified by the Yip-Saw classification into three categories, and the procedure should be approached with special attention due to the fragility of coronary arteries in these patients. Further imaging techniques that can be of use are OCT, IVUS, CTCA. Initial management is directed toward treating the myocardial infarction and its complications. A significant portion of SCAD can be managed conservatively, and the PCI is used to maintain a grade 3 TIMI flow with minimal intervention. In case there are clinical or anatomical high-risk features present, the patient can be referred to CABG if it is available. Other than managing the myocardial infarction, medical management plays a role in managing chronic chest pain, preventing recurrence of SCAD, treating extracoronary vascular disorders, and improving patients’ quality of life. Patients with left ventricular dysfunction and patients after PCI are managed according to the current guidelines. Dual antiplatelet therapy is prescribed to all patients following PCI, in the acute phase of SCAD, and for up to 1 year to patients who are treated medically. After the first year, it is needed to tailor the treatment to each patient individually. Aiming to preserve and improve the quality of patients’ lives, they should receive regular followup and timely diagnosis and treatment for possible issues, which will, along with cardiovascular rehabilitation, aid in reaching this goal.

Although pioneering preclinical research on the use of cell therapy for cardiac regeneration was conducted in the last quarter of the 20th century,1,2 a preponderance of advances have occurred in the 21st century, making this a relatively young field. In the first important clinical trial of cardiac cell therapy, begun in 2001, Menasche et al3 implanted autologous skeletal myoblasts into postinfarct scar at the time of coronary artery bypass surgery. Although the transplanted cells remained viable and exhibited contraction, they formed the nidus for serious ventricular tachyarrhythmias, which led to premature discontinuation of the trial. Despite this outcome, the trial energized the field, accelerating both preclinical and clinical research, albeit not with skeletal myoblasts. The extensive progress in cardiac regeneration is reviewed in this Compendium, and as occurs frequently in science, important observations have led to more questions and challenges (Table). View this table: Table. Important Challenges to Cell Therapy for Cardiac Regeneration Many cell types have been evaluated as candidates for cardiac regeneration. Among the earliest clinical trials, Zeiher’s group infused autologous bone marrow-derived progenitor cells into the coronary arteries of patients with acute,4 as well as healed myocardial infarction (MI)5 and reported improvements in left ventricular (LV) function. However, these results have not been fully confirmed by later studies, as pointed out in the review in the Compendium by Banarjee, Bolli, and Hare.6 Pittenger et al7 were among the first to direct attention to bone marrow-derived (stromal) mesenchymal stem cells (MSCs), emphasizing that these cells proliferated extensively in culture and suggesting that they could be attractive candidates for transplantation. In 2004, Chen et al8 reported that intracoronary infusion of autologous bone marrow-derived MSCs improved cardiac function. Zimmet and Hare pointed out that MSCs lack histocompatibility type II markers and elude rejection by …

Previous studies have demonstrated improvement of regional wall motion and global left ventricular function after successful recanalization of chronic total occlusion in coronary artery. However, the difference of benefits of recanalization between infarct site and noninfarct site is unknown. This study assessed the changes in left ventricular ejection fraction, regional wall motion after successful angioplasty of chronic total occlusions with or without previous myocardial infarction. This study also evaluated the factors that influenced the outcome of left ventricular function. We retrospectively studied 75 patients with a successfully recanalized chronic total occlusion in native coronary artery. Left ventriculograms were obtained at baseline and after 6 months. Global and regional left ventricular function were determined. The patients were divided into two groups. Group 1 comprised patients without previous myocardial infarction in the territories of total occlusion vessel that was recanalized. Group 2 comprised patients with previous myocardial infarction in the territories of total occlusion vessel that was recanalized. Left ventricular ejection fraction increased from 53.2% +/- 16.3% at baseline to 57.3% +/- 20.1% at 6-month follow-up in the whole group (P = 0.001). In group 1 patients, the evolution of left ventricular (LV) ejection fraction increased from 59.5% +/- 13.7% to 67.3% +/- 14.6% (P < 0.001). In group 2 patients, the evolution of LV ejection fraction increased, but not significantly, from 48.9% +/- 16.2% to 50.5% +/- 16.9% (P = NS). The evolution of LV ejection fraction increased from 47.6% +/- 17.4% to 50.8% +/- 17.5% (P < 0.05) in the subgroup of recanalization in infarct-related vessel that had rich collateral circulation and had long-term patency. The regional wall motion all significantly improved in group 1 patients (P < 0.05). The regional wall motion did not change in group 2 patients (P = NS). The influence of recanalization of chronic coronary occlusions on the improvement of left ventricular global function was different between myocardial infarction and nonmyocardial infarction patients. The left ventricular function did not improve in myocardial infarction patient. Regional wall motion improved in patients without previous myocardial infarction. For reliable improvement of left ventricular function after recanalization of chronic total occlusions, evidence (not only by symptom or treadmill test) of viable myocardium in recanalized vessel is important. It is also important to keep patency of infarct-related vessel that has good collateral circulation for improving the left ventricular function.

A 50-year-old man, a former smoker, presented with an ST-segment elevation anterior myocardial infarction that was treated with thrombolysis in another center. Because of the absence of reperfusion criteria, he was referred to our hospital for a rescue coronary intervention. A transthoracic echocardiogram showed that the overall left-ventricle systolic function was preserved but with apical akinesia. Coronary angiography revealed an occlusive lesion (100%) in the mid-left anterior descending coronary artery distal to a segment with a tapering caliber (Figure 1A). At that time, the patient was asymptomatic, and, therefore, a conservative management was decided, including dual antiplatelet therapy and full anticoagulation. Biomarkers included elevated creatine kinase (peak: 926 U/L; n<190), creatine kinase-MB peak (peak: 36.4 ng/mL; n<5), and troponin I peak (peak: 15.90 ng/mL; n<0.2). A new coronary angiogram performed 7 days later revealed a complete recanalization of the left anterior descending …

Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, especially in young and middle-aged women. Little is known about characteristics of SCAD across age groups. While SCAD can occur across a broad age spectrum, age-specific differences in SCAD manifestations are underexplored. Methods: Sub-analysis of the iSCAD Registry with stratification of patients into 3 age groups at time of index SCAD: &lt; 40 years (y), 40-65 y and 65+ y. Data are reported for patients with complete investigator case report form and patient baseline questionnaire. Differences of characteristics between groups were calculated across strata using Kruskal-Wallis test or chi-square test, with statistical significance defined as p &lt; 0.05. Results: Among 960 eligible participants, mean age was 49.8 y and 93.4% were female (no difference by group). Overall, 88.7% of participants were White. While racial distribution was similar across age groups (p=0.20), the &lt;40 y group had a numerically higher proportion of Black patients (11.2% &lt; 40 y vs. 6.3% 40-65 y vs. 2.4% 65+y). Patients ≥40 years were more likely to have hypertension and hyperlipidemia while patients &lt;40y were more likely to have an inherited connective tissue disorder and pregnancy-related SCAD. Extra-coronary vascular abnormalities were prevalent in all 3 but fibromuscular dysplasia (FMD) was less common in &lt;40 y group. Emotional and physical stressors were not different across groups. Primary clinical presentation of SCAD was most commonly non-ST elevation MI across all groups (p=NS). Younger patients (&lt;40 y) had predominant LAD involvement (69.3% vs. 59.6% 40-65 y vs. 38.2% 65+ y, p&lt; 0.01). Compared to older groups, patients &lt;40 y were less frequently managed with medical therapy only and more frequently received revascularization and mechanical circulatory support. Conclusions: In this large multicenter SCAD cohort, age-stratified analyses revealed distinct clinical and angiographic profiles. Patients &lt;40 y had more pregnancy-related SCAD and connective tissue disorders, while older patients had more traditional risk factors and FMD. LAD involvement and revascularization were more common in younger patients. These findings underscore the importance of age-specific approaches to SCAD care.

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.

Introduction: Spontaneous coronary artery dissection (SCAD), once considered rare, is now recognized to account for approximately 4% of acute coronary syndrome cases and up to 22-43% of myocardial infarction cases in women. Although SCAD patients lack typical atherosclerotic risk factors, the prevalence of hypertension and hyperlipidemia is like that of age-matched controls, further complicating the diagnosis. Case description: A 45-year-old female with a history of hypertension, obstructive sleep apnea, and sickle cell trait presented with a one-month history of intermittent chest pain. Initially, the pain was central, non-radiating, described as “air stuck in my chest,” and lasted 30 minutes. It was not associated with exertion and increased in frequency over the month. On presentation, the pain intensified and radiated down her right arm. She had no family history of premature coronary artery disease. On examination, she was hemodynamically stable, and her physical exam was unremarkable, aside from a BMI of 44. Laboratory evaluation showed a hemoglobin level of 13.8 g/dL, an unremarkable complete metabolic panel, a lipase level of 17 U/L, total cholesterol of 202 mg/dL, and LDL of 140 mg/dL. Beta HCG was negative. Initial troponin was 402 ng/L and peaked at 6620 ng/L. The electrocardiogram showed a normal sinus rhythm without ischemic changes. Echocardiogram revealed mild concentric left ventricular hypertrophy, normal left ventricular systolic function, and normal wall motion. Coronary angiography demonstrated 90% distal narrowing of the right postero-lateral branch, while the left anterior descending and left circumflex arteries were normal but tortuous. The patient was diagnosed with type 2B SCAD, with no coronary intervention performed, and subsequently discharged on dual antiplatelet therapy, metoprolol, and atorvastatin. Discussion: Patients with SCAD typically present with acute chest pain, often radiating to the arm in 52% of cases. However, some patients report atypical pain, described as burning, pleuritic, tearing, or positional. Interestingly, this patient described her pain as feeling like “air being stuck in her chest,” and her symptoms persisted for one month prior to presentation. An accurate diagnosis of SCAD is imperative, as management differs from that of a typical atherosclerotic plaque rupture myocardial infarction. Acutely, a conservative approach without coronary intervention is preferred. Additionally, these patients require counselling on the risks of recurrent SCAD and persistent chest pain, among other concerns. A high index of suspicion should be maintained, especially in this demographic, to initiate timely treatment and avert mortality.

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome. Many patients with SCAD have associated coronary risk factors. However, the implications of arterial hypertension in SCAD patients remain unknown. This study sought to assess the clinical implications of arterial hypertension in a nationwide cohort of patients with SCAD. The Spanish SCAD registry (NCT03607981) prospectively enrolled 318 consecutive patients. All coronary angiograms were centrally analyzed to confirm the diagnosis of SCAD. Patients were classified according to the presence of arterial hypertension. One-hundred eighteen patients (37%) had a diagnosis of arterial hypertension. Hypertensive SCAD patients were older (60 ± 12 vs. 51 ± 9 years old) and had more frequently dyslipidemia (56 vs. 23%) and diabetes (9 vs. 3%) but were less frequently smokers (15 vs. 35%) than normotensive SCAD patients (all P < 0.05). Most patients in both groups were female (90 vs. 87%, NS) and female patients with hypertension were more frequently postmenopausal (70 vs. 47%, P < 0.05). Hypertensive SCAD patients had more severe lesions and more frequently multivessel involvement (15 vs. 7%, P < 0.05) and coronary ectasia (19 vs. 7%, P < 0.05) but showed a similar prevalence of coronary tortuosity (34 vs. 26%, NS). Revascularization requirement was similar in both groups (17 vs. 26%, NS) but procedural success was significantly lower (65 vs. 88%, P < 0.05) and procedural-related complications more frequent (65 vs. 41%, P < 0.05) in SCAD patients with hypertension. Patients with SCAD and hypertension are older, more frequently postmenopausal and have more coronary risk factors than normotensive SCAD patients. During revascularization SCAD patients with hypertension obtain poorer results and have a higher risk of procedural-related complications (NCT03607981).

Primary spontaneous coronary dissectİon in a young male and the role of intravascular ultrasonography for diagnosis and treatment

Coronary artery dissection is a rare cause of acute coronary syndrome. Most cases occur in women during the peripartum period, most likely influenced by hormonal changes, hemodynamic stress and modifications in the immune system during pregnancy. The pathogenesis of coronary artery dissection is unknown, hence numerous theories have been postulated such as pregnancy-related conditions, the presence of connective tissue disorders, trauma, etc. The clinical presentation ranges from asymptomatic patients to the whole spectrum of acute coronary syndrome manifestations. The management of these patients requires a multidisciplinary approach, with two options: medical therapy or an invasive approach, with percutaneous coronary intervention or coronary artery bypass graft surgery. The choice of treatment options depends on the hemodynamic status of the patient, the extension of the dissection and the myocardial territory at risk. In this case report we present a 38-year-old female who had a coronary artery dissection seven days postpartum. Coronary catheterization showed dissection of the left main coronary artery that extended until the circumflex artery. An intra-aortic balloon pump was installed and the patient then underwent coronary artery bypass graft surgery, with satisfactory results.

Spontaneous coronary artery dissection (SCAD) is an emerging cause of acute coronary syndrome (ACS), disproportionately affecting women. Data on the management and outcomes of these patients remain limited, especially regarding the overall risk of major adverse cardiovascular events (MACE) and arrhythmic complications. This study aimed to investigate the incidence and independent predictors of MACE in SCAD patients. In this single-center, prospective observational study, 76 patients with SCAD were enrolled. Clinical follow-up (mean duration: 4.03±3.4 years) was conducted through in-hospital visits and electronic database monitoring. The primary composite endpoint included MACE, defined as cardiovascular (CV) rehospitalization and death, the secondary endpoint included supraventricular and ventricular arrhythmias. All the patients enrolled were characterized by their clinical presentation, underlying risk factors, and triggers for SCAD. Of the 76 patients, 45 (59.2%) received medical therapy alone, 27 (35.5%) underwent percutaneous coronary intervention (PCI), and four (5.2%) had coronary artery bypass grafting (CABG). During the follow-up period, the primary endpoint occurred in 34 patients (44.7%), with CV rehospitalization as the main cause of MACE (31 patients, 40.8%). Coronary revascularization emerged as the only independent predictor of MACE (HR=1.92, 95% CI 1.13-3.21, P=0.035). The secondary endpoint occurred in 13 patients (17.1%). Although SCAD is often considered a rare and relatively benign cause of ACS, our findings reveal a high rate of CV rehospitalization and mortality. Furthermore, mid-term follow-up indicates that SCAD is associated with supraventricular and non-sustained ventricular arrhythmias, with limited impact on prognosis and generally requiring pharmacological optimization.

Background: Spontaneous coronary artery dissection (SCAD) is rarely encountered as a primary cause of acute coronary syndrome (ACS). There is a paucity of studies involving SCAD, especially in the Indian population. Aims: We aim to study the clinical and angiographic characteristics and in-hospital outcomes of ACS patients whose angiogram incidentally shows SCAD as the cause of ACS and the management strategies opted. Methods: This is a prospective and retrospective observational study. All coronary angiograms of patients with ACS, either ST-segment elevation myocardial infarction (STEMI) or unstable angina non-STEMI, underwent within 72 h of admission, were analyzed and those patients with Saw classification Type I SCAD were included in the study. Clinical and angiographic characteristics, in-hospital outcomes, and management strategies of patients with SCAD were recorded. Results: Of the total 70 cases with SCAD included in the study, 66 (94.28%) were male. Smoking was the most common risk factor seen in 22 (31.4%) cases. STEMI was the most common presentation seen in 44 (62.8%) subjects. Single-vessel involvement was seen in 67 (95.7%) patients. Significant stenosis, i. e., >70% luminal narrowing was seen in 40 (57.1%) patients. Root cause analysis (RCA) is the most common artery to be involved with 35 (50%) cases. Majority of the cases, i.e., 60 (85.7%) cases had thrombolysis in myocardial infarction 3 flow. The majority was managed conservatively. Percutaneous transluminal coronary angioplasty (PTCA) was done successfully in 18.5% of patients. Conclusion: Indian subjects, as observed in this study, differ significantly in their profile compared to the Western population. Indian subjects are predominantly middle-aged males with a significant proportion having traditional risk factors, and they tolerate thrombolysis better, success rates of PTCA are much higher, RCA is the most commonly involved artery as opposed to left anterior descending in Western population and more than half of the patients have atherosclerotic disease involving other arteries.

Spontaneous coronary artery dissection (SCAD) is the most important cause of acute coronary syndromes during pregnancy and in the post-partum period and involves a spontaneous intimal tear or intramural haematoma of a coronary artery. Pregnancy-associated SCAD accounts for a minority of SCAD cases but is associated with a high rate of adverse events. We present a series of three cases with pregnancy-associated SCAD. All patients presented with acute coronary syndromes in the post-partum period, between 12 days and 5 months after delivery. They all had additional conditions that are associated with SCAD, such as fibromuscular dysplasia and migraine. The management of one patient was uncomplicated, however, the courses of the other two were characterized by adverse events. One presented after an out-of-hospital cardiac arrest, the other presented with multivessel SCAD and developed progression and recurrence of SCAD during follow-up. In conclusion, the patients could be successfully treated conservatively and were in good condition at their latest follow-ups. This case series highlights the wide range of clinical courses that could exist in pregnancy-associated SCAD, from a benign manifestation to a life-threatening condition. Importantly, those patients are at an increased risk for acute and late adverse events.

Spontaneous Coronary Artery Dissection Associated With β-HCG Injections and Fibromuscular Dysplasia