Spontaneous coronary artery dissection (SCAD) is typically due to either a tear in the coronary artery’s intimal layer leading to blood propagation into the media layer and the creation of two distinct lumens (true and false) compromising blood flow to the myocardium. SCAD accounts for only 0.5-1% of acute coronary syndrome (ACS) cases, but in women ≤50 years old, it is often underdiagnosed and may represent nearly a quarter of presentations. The “textbook” patient is typically a young, peripartum woman, but SCAD should also be considered in postmenopausal women.
Patients sometimes have a history of connective tissue disorders, fibromuscular dysplasia, or hormonal fluctuations (as seen in pregnancy, IVF, etc.). Symptoms are similar to ACS, including chest pain, diaphoresis, and dyspnea. Coronary angiography is the gold standard for diagnosis with various angiographic patterns recognized for SCAD.
In stable patients, conservative therapy is preferred due to the high rates of spontaneous healing and the procedural risk of worsening dissection during PCI. In contrast, unstable patients (hemodynamic compromise, left main involvement, ongoing ischemia) may require PCI or CABG, though PCI carries a high technical failure rate and risk of propagation.
At the end of the day, we have to consider SCAD in patients who present with ACS-symptoms without atherosclerotic risk factors.
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