Spontaneous coronary artery dissection: etiology and recurrence

ABSTRACT

Introduction: Spontaneous coronary artery dissection (SCAD) is an increasingly appreciated cause of acute myocardial infarction (AMI) and sudden cardiac death most often affecting young to middle-aged women with few conventional cardiovascular risk factors.

Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 04/30/2019). Authors review the key clinical features of SCAD and highlight what is known regarding its pathophysiology and associated factors. The relationship between SCAD and other systemic vasculopathies, notably fibromuscular dysplasia (FMD) is also discussed. Authors also mention the management of acute SCAD along with considerations for long term follow-up such as chest pain syndrome, extracoronary vasculopathy screening, and recurrent SCAD.

Expert opinion: Our understanding regarding the association of SCAD and other arteriopathies such as FMD is anticipated to grow. In addition, progress is likely to be made in our efforts to predict recurrent SCAD risk and define potential preventative strategies, possibly through the incorporation of adjunctive imaging.

KEYWORDS:

• Spontaneous coronary artery dissection
• myocardial infarction
• fibromuscular dysplasia
• women’s health
• acute coronary syndrome

Article Highlights

• Spontaneous coronary artery dissection (SCAD) is an uncommon but important non-atherosclerotic cause of acute coronary syndrome especially among young to middle-aged women with few to no traditional cardiovascular risk factors.

• Two proposed mechanisms for SCAD are: 1. Primary intimal tear leading to a false lumen and hematoma (‘outside-in’); 2. Hemorrhage within the vasa vasorum of the arterial wall followed by dissection due to increased pressure from the hematoma (‘inside-out’).

• Strong associations between SCAD, arterial tortuosity, and extracoronary vascular abnormalities such as fibromuscular dysplasia have been noted, suggesting that SCAD may belong to a spectrum of systemic arteriopathies.

• A combination of hormonal and hemodynamic changes may contribute to pregnancy-associated SCAD in a susceptible patient. Compared to non-pregnancy-associated SCAD, these patients tend to be younger, have less extracoronary vascular abnormalities, and have more severe clinical presentations.

• Recurrent SCAD may occur with estimates of 11–19% of the patients. Increased coronary tortuosity and hypertension have been associated with risk of recurrence in limited retrospective studies. More research is necessary to further define risk and preventative measures.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.