Spontaneous coronary artery dissection: What we know so far?

Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS). Although it is difficult to differentiate SCAD from other causes of ACS based on the clinical presentation, some patient characteristics can aid the clinician in considering SCAD as a diagnosis. Namely, SCAD is far more common in women, especially in the peripartum period, and patients often do not have typical risk factors associated with atherosclerosis-related myocardial infarction. Furthermore, there is an association with FMD, migraine, and inherited connective tissue disorders. The primary pathophysiologic disturbance is the separation of layers of the coronary artery, either by hemorrhage from the vasa vasorum and formation of an intramural hematoma or by blood entering the vessel wall through an endothelial disruption thus creating a false lumen. The most common presentations are myocardial infarction, cardiogenic shock, and ventricular arrhythmias, while the most common presenting symptom is chest pain. The gold standard in diagnostics is coronary angiography. Angiography findings can be classified by the Yip-Saw classification into three categories, and the procedure should be approached with special attention due to the fragility of coronary arteries in these patients. Further imaging techniques that can be of use are OCT, IVUS, CTCA. Initial management is directed toward treating the myocardial infarction and its complications. A significant portion of SCAD can be managed conservatively, and the PCI is used to maintain a grade 3 TIMI flow with minimal intervention. In case there are clinical or anatomical high-risk features present, the patient can be referred to CABG if it is available. Other than managing the myocardial infarction, medical management plays a role in managing chronic chest pain, preventing recurrence of SCAD, treating extracoronary vascular disorders, and improving patients’ quality of life. Patients with left ventricular dysfunction and patients after PCI are managed according to the current guidelines. Dual antiplatelet therapy is prescribed to all patients following PCI, in the acute phase of SCAD, and for up to 1 year to patients who are treated medically. After the first year, it is needed to tailor the treatment to each patient individually. Aiming to preserve and improve the quality of patients’ lives, they should receive regular followup and timely diagnosis and treatment for possible issues, which will, along with cardiovascular rehabilitation, aid in reaching this goal.