Spontaneous coronary artery dissection: Aggressive vs. conservative therapy

Department of Internal Medicine, Division of Cardiovascular Diseases, Howard University Hospital, Washington, DC, USA.
The Journal of invasive cardiology (Impact Factor: 0.95). 05/2010; 22(5):222-8.
Source: PubMed


Spontaneous coronary artery dissection (SCAD) is a rare condition that commonly presents as an acute coronary event in the younger population, especially in females of childbearing age. Generally, there is no consensus on the etiology, prognosis, and treatment of SCAD.
The Medline database was searched for "spontaneous coronary artery dissection" between 1931 and 2008. A total of 440 cases of SCAD were identified. Demographic data were analyzed with either the Student's t-test or the chi-square test for categorical and nominal variables, respectively. Kaplan-Meier outcome analysis was used to assess the outcome of a given treatment for all patients after 1990.
SCAD was found more commonly in females with 308 (70%) cases. Pregnancy was associated with SCAD in 80 (26.1%) cases. Among pregnant patients, 67 (83.8%) developed SCAD in the postpartum period and 13 (16.2%) patients in the prepartum period. Analysis of treatment modalities showed that 21.2% of the patients who were conservatively managed after the initial diagnosis eventually required surgical or catheter-based intervention compared to 2.5% of patients who were initially treated with an aggressive strategy. Kaplan-Meier analysis showed that patients with an isolated single lesion in left or right coronary artery had a statistically significant better outcome when treated with an early aggressive strategy, including coronary artery bypass grafting (CABG) or stent placement as compared to a conservative strategy (p = 0.023, p = 0.006, respectively).
Early intervention with either CABG or percutaneous coronary intervention following the diagnosis of SCAD leads to a better outcome and less need for further intervention.

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    • "Although it is not related to atherosclerosis, its origin is unknown. Case series of SCAD excluding atherosclerotic dissection demonstrate a young, female preponderance with a low burden of atherosclerotic risk factors and an association with peripartum or postpartum status [1] [2] [3] [4] [5] [6] [7]. Other SCAD associations identified from case reports include connective tissue disorders, spasm, and excessive exercise [1,4,8–11]. "
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    ABSTRACT: Spontaneous coronary artery dissection (SCAD) is an infrequent but increasingly recognized cause of acute coronary syndrome (ACS). Previous case reports demonstrated that this condition occurs in young females with a low atherosclerotic risk factor burden and may be associated with peripartum or postpartum status. The purpose of this study was to review patients with angiographically confirmed SCAD to provide additional insight into the diagnosis and treatment of this condition. We screened medical records of all patients with ACS from March 2001 to November 2012. From these patients, we selected patients with SCAD based on coronary angiographic review. Of a total of 1159 ACS patients, 10 patients (0.86%) were diagnosed with SCAD. The mean age of these patients was 46 years, and 9 were female. ST-elevation myocardial infarction (STEMI) was observed in 9 patients and 5 patients had no coronary risk factors. One patient was treated conservatively with medication alone and 3 patients underwent thrombectomy. Balloon angioplasty was performed in 2 patients, and a bare metal stent was placed in one of these patients later. In the remaining 4 patients, bare metal stents were implanted emergently. Follow-up coronary angiography showed appropriate repair of SCAD in all 10 patients. In our experience, the clinical features of SCAD appear to be similar to those reported previously. SCAD appears to be rare, but it should be considered in ACS patients, especially in younger females.
    Journal of Cardiology 09/2013; 63(2). DOI:10.1016/j.jjcc.2013.07.001 · 2.78 Impact Factor
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    • "Conservative medical therapy is a reasonable first option in mid- or distal single vessel dissection with a lumen diameter limitation <50% and TIMI grade 2 or 3 flow in the affected coronary artery.5)9)19) However, some studies have demonstrated that early intervention with either PCI or coronary artery bypass graft (CABG) following the diagnosis of SCAD leads to a better outcome.20) The role of thrombolytics is controversial, associated with the extension of dissection due to increased blood in the vessel wall or hematoma causing compression of the true lumen.9) "
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    ABSTRACT: Spontaneous coronary artery dissection (SCAD) is a rare and occasionally life-threatening cause of acute coronary syndrome. Patients may present with clinical scenarios ranging from angina pectoris to cardiogenic shock to sudden cardiac death, and it may be a potentially life-threatening condition if not recognized. However, its etiology, pathophysiology and optimal therapeutic strategies have not been well understood. SCAD is diagnosed on the basis of coronary angiography, but complementary techniques as such intravascular ultrasound (IVUS) and optical coherence tomography should be considered for diagnostic clarification where appropriate. Likewise, the selection of treatment strategy depends upon the clinical manifestation, location and the extent of dissection and amount of ischemic myocardium at risk. Herein, we present the case of a 35-year-old woman who presented with acute myocardial infarction. She was diagnosed by IVUS with spontaneous diffuse dissection of the left anterior descending artery without atheroma, treated with percutaneous coronary stenting, and had a favorable clinical course and was discharged on medical therapy.
    Korean Circulation Journal 07/2013; 43(7):491-6. DOI:10.4070/kcj.2013.43.7.491 · 0.75 Impact Factor
    • "Shamloo et al. recently did a systematic analysis of all published cases and concluded thus: a) About 20% of cases were diagnosed postmortem and the rest by coronary angiogram; b) isolated single vessel involvement was the most frequent lesion; c) early intervention (either stent or bypass graft surgery) strategy had a superior outcome compared to conservative management; and d) administration of thrombolytics (before diagnosis of SCAD) resulted in worsening of condition in 60% of patients.[11] "
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    ABSTRACT: Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome or sudden cardiac death. SCAD has most frequently been described as presenting as an acute coronary syndrome in females during the peripartum period. It may also be associated with autoimmune and collagen vascular diseases, Marfan's syndrome, chest trauma, and intense physical exercise. The most common presentation of SCAD is the acute onset of severe chest pain associated with autonomic symptoms. This condition has a high mortality rate if not identified and treated promptly. Here, we present a case of SCAD presenting with stroke, followed by a brief review.
    Heart Views 10/2012; 13(4):149-54. DOI:10.4103/1995-705X.105737
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