Spontaneous coronary artery dissection
- Pamela S Douglas, MD
Pamela S Douglas, MD
- Ursula Geller Professor of Research in Cardiovascular Diseases
- Duke University Medical Center
- Jacqueline Saw, MD, FRCPC, FACC
Jacqueline Saw, MD, FRCPC, FACC
- Clinical Associate Professor
- University of British Columbia
- Vancouver General Hospital
- Section Editors
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is a rare cause of acute myocardial infarction. It is more common in younger patients and in women. This topic will focus on non-atherosclerotic SCAD. Other aspects of coronary heart disease in women are discussed separately. (See "Clinical features and diagnosis of coronary heart disease in women".)
PATHOLOGY AND PATHOPHYSIOLOGY
The underlying mechanism of non-atherosclerotic spontaneous coronary artery dissection (NA-SCAD) is not fully understood, but an intimal tear or bleeding of vasa vasorum with intramedial hemorrhage has been proposed . Both result in creation of a false lumen filled with intramural hematoma . Pressure-driven expansion of the false lumen by an enlarging hematoma may lead to luminal encroachment and subsequent myocardial ischemia and infarction. Atherosclerotic SCAD is a mechanistically distinct variant of SCAD and is typically limited in extent by medial atrophy and scarring . NA-SCAD, on the other hand, can result in extensive dissection lengths, especially in the presence of arterial fragility from predisposing arteriopathies, and intracoronary imaging studies clearly show the absence of atherosclerosis in these cases [4,5].
In pregnant or early postpartum women, dissection may be a consequence of increased physiological hemodynamic stresses or from hormonal effects weakening the coronary arterial wall [6,7]. The exposure to recurrent and chronic hormonal pregnancy changes can further increase SCAD risks in women with multiple previous births (multiparity), and dissection in all arterial beds are more common during pregnancy . (See "Acquired heart disease and pregnancy", section on 'Myocardial infarction'.)
Intramural hematoma involving the outer two-thirds of the media is common. Histologically, an inflammatory reaction (eg, eosinophilic infiltrates) in the adventitia has been described, suggestive of periarteritis that may breakdown the medial-adventitial layer predisposing the artery to dissection. However, this inflammatory response may be reactive rather than causative .
One retrospective study has proposed that coronary artery tortuosity may be a marker for or a potential mechanism for SCAD . In this study, the coronary angiograms of 246 patients with SCAD were compared with 313 controls. Tortuosity, as defined by the presence of ≥3 consecutive curvatures of 90 to 180 degrees measured at end-diastole in a major epicardial coronary artery ≥2 mm in diameter, was found in 78 and 17 percent, respectively. However, the presence of coronary tortuosity was also associated with extracoronary vasculopathy (eg, fibromuscular dysplasia); as such, it is more likely that the tortuosity, similar to dissection, is a manifestation of the underlying predisposing vasculopathy.
- Alfonso F. Spontaneous coronary artery dissection: new insights from the tip of the iceberg? Circulation 2012; 126:667.
- Alfonso F, Bastante T. Spontaneous coronary artery dissection: novel diagnostic insights from large series of patients. Circ Cardiovasc Interv 2014; 7:638.
- Isner JM, Donaldson RF, Fortin AH, et al. Attenuation of the media of coronary arteries in advanced atherosclerosis. Am J Cardiol 1986; 58:937.
- Saw J, Mancini GB, Humphries K, et al. Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging. Catheter Cardiovasc Interv 2016; 87:E54.
- Alfonso F, Paulo M, Gonzalo N, et al. Diagnosis of spontaneous coronary artery dissection by optical coherence tomography. J Am Coll Cardiol 2012; 59:1073.
- Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death. Heart 1996; 75:451.
- Vijayaraghavan R, Verma S, Gupta N, Saw J. Pregnancy-related spontaneous coronary artery dissection. Circulation 2014; 130:1915.
- Eleid MF, Guddeti RR, Tweet MS, et al. Coronary artery tortuosity in spontaneous coronary artery dissection: angiographic characteristics and clinical implications. Circ Cardiovasc Interv 2014; 7:656.
- Saw J, Ricci D, Starovoytov A, et al. Spontaneous coronary artery dissection: prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013; 6:44.
- Saw J, Aymong E, Sedlak T, et al. Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes. Circ Cardiovasc Interv 2014; 7:645.
- Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012; 126:579.
- Saw J, Poulter R, Fung A, et al. Spontaneous coronary artery dissection in patients with fibromuscular dysplasia: a case series. Circ Cardiovasc Interv 2012; 5:134.
- Michelis KC, Olin JW, Kadian-Dodov D, et al. Coronary artery manifestations of fibromuscular dysplasia. J Am Coll Cardiol 2014; 64:1033.
- Judge DP, Dietz HC. Marfan's syndrome. Lancet 2005; 366:1965.
- Adès LC, Waltham RD, Chiodo AA, Bateman JF. Myocardial infarction resulting from coronary artery dissection in an adolescent with Ehlers-Danlos syndrome type IV due to a type III collagen mutation. Br Heart J 1995; 74:112.
- Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009; 74:710.
- Nishiguchi T, Tanaka A, Ozaki Y, et al. Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 2016; 5:263.
- Saw J, Aymong E, Mancini GB, et al. Nonatherosclerotic coronary artery disease in young women. Can J Cardiol 2014; 30:814.
- Alfonso F, Paulo M, Lennie V, et al. Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy. JACC Cardiovasc Interv 2012; 5:1062.
- Lempereur M, Gin K, Saw J. Multivessel spontaneous coronary artery dissection mimicking atherosclerosis. JACC Cardiovasc Interv 2014; 7:e87.
- DeMaio SJ Jr, Kinsella SH, Silverman ME. Clinical course and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989; 64:471.
- Jorgensen MB, Aharonian V, Mansukhani P, Mahrer PR. Spontaneous coronary dissection: a cluster of cases with this rare finding. Am Heart J 1994; 127:1382.
- Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. Ann Intern Med 1996; 125:751.
- Saw J. Coronary angiogram classification of spontaneous coronary artery dissection. Catheter Cardiovasc Interv 2014; 84:1115.
- Tweet MS, Eleid MF, Best PJ, et al. Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circ Cardiovasc Interv 2014; 7:777.
- Higgins GL 3rd, Borofsky JS, Irish CB, et al. Spontaneous peripartum coronary artery dissection presentation and outcome. J Am Board Fam Med 2013; 26:82.
- Vrints CJ. Spontaneous coronary artery dissection. Heart 2010; 96:801.
- Saw J. Spontaneous coronary artery dissection. Can J Cardiol 2013; 29:1027.
- Saw J, Sedlak T, Ganesh SK, et al. Cardiology patient page. Spontaneous coronary artery dissection (SCAD). Circulation 2015; 131:e3.
- Tweet MS, Gulati R, Hayes SN. What Clinicians Should Know Αbout Spontaneous Coronary Artery Dissection. Mayo Clin Proc 2015; 90:1125.