Circulation AHA SCIENTIFIC STATEMENT
Spontaneous Coronary Artery Dissection: Current State of the Science A Scientific Statement From the American Heart Association
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ABSTRACT: Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.
pontaneous coronary artery dissection (SCAD) is defined as an epicardial coronary artery dissection that is not associated with atherosclerosis or trauma and not iatrogenic. The predominant mechanism of myocardial injury occurring as a result of SCAD is coronary artery obstruction caused by formation of an intramural hematoma (IMH) or intimal disruption rather than atherosclerotic plaque rupture or intraluminal thrombus. Since the first description of SCAD by Pretty1 in 1931 at autopsy, our understanding of it has evolved tremendously during the past 8 decades, especially in the past 5 years. On the basis of isolated case reports and small series, SCAD was initially described as a rare and almost universally fatal cause of acute coronary syndrome (ACS), myocardial infarction (MI), and sudden cardiac death in peripartum women,2–4 but contemporary reports have refuted these misconceptions. Indeed, advances in our understanding of the epidemiology of SCAD, the availability of intravascular imaging techniques,5 the development of SCAD-specific angiographic classification,6 heightened awareness among providers, and parallel efforts by patients7 using social media to broadly disseminate information suggest that SCAD is far more common than previously thought, especially in young women. In addition, SCAD has unique risk factors and associated conditions and different diagnostic, therapeutic, and prognostic implications compared with atherosclerotic coronary disease.8–17 Despite these advances, dissemination of new knowledge has been slow, and SCAD continues to be misdiagnosed, underdiagnosed, and managed as atherosclerotic ACS, which may harm patients with SCAD. An emphasis on accurate diagnosis is key to not only providing early supportive care but also Circulation. 2018;137:00–00. DOI: 10.1161/CIR.0000000000000564
Sharonne N. Hayes, MD, FAHA, Chair Esther S.H. Kim, MD, MPH, FAHA, Co-Chair Jacqueline Saw, MD, FAHA, Co-Chair David Adlam, BA, BM, BCh, DPhil Cynthia Arslanian-Engoren, PhD, RN, FAHA Katherine E. Economy, MD, MPH Santhi K. Ganesh, MD, FAHA Rajiv Gulati, MD, PhD Mark E. Lindsay, MD, PhD, FAHA Jennifer H. Mieres, MD, FAHA Sahar Naderi, MD, MHS Svati Shah, MD, MHS, FAHA David E. Thaler, MD, PhD, FAHA Marysia S. Tweet, MD Malissa J. Wood, MD On behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council
Key Words: AHA Scientific Statements ◼ coronary artery dissection, spontaneous ◼ fibromuscular dysplasia ◼ myocardial infarction ◼ wom