Spontaneous coronary artery dissection: New insights into diagnosis and treatment

Fernando Alfonso, Teresa Bastante, Marcos García-Guimaraes, Eduardo Pozo, Javier Cuesta, Fernando Rivero, Amparo Benedicto, Paula Antuña, Teresa Alvarado, Rajiv Gulati, Jacqueline Saw

Research output: Contribution to journalReview article

31 Scopus citations

Abstract

Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middleaged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.

Original languageEnglish (US)
Pages (from-to)696-706
Number of pages11
JournalCoronary Artery Disease
Volume27
Issue number8
DOIs
StatePublished - Jan 1 2016

    Fingerprint

Keywords

  • acute coronary syndrome
  • conservative strategy
  • coronary angiography
  • fibromuscular dysplasia
  • intravascular ultrasound
  • myocardial infarction
  • optical coherence tomography
  • revascularization
  • spontaneous coronary artery dissection
  • stents

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Alfonso, F., Bastante, T., García-Guimaraes, M., Pozo, E., Cuesta, J., Rivero, F., Benedicto, A., Antuña, P., Alvarado, T., Gulati, R., & Saw, J. (2016). Spontaneous coronary artery dissection: New insights into diagnosis and treatment. Coronary Artery Disease, 27(8), 696-706. https://doi.org/10.1097/MCA.0000000000000412