29 - Spontaneous Coronary Artery Dissection

Question 1

What is spontaneous coronary artery dissection?

Answer 1

Separation of the coronary artery media by hemorrhage with or without an associated intimal teat and isn’t associated with aortic root dissection nor is it a consequence of coronary angioplasty or angiography, cardiac surgery or chest trauma

Question 2

What demographic is most commonly affected by SCAD?

Answer 2

• Occurs most often in young women (age

Question 3

Which coronary artery is the most frequently involved vessel?

Answer 3

Left anterior descending coronary artery (LAD)

Question 4

What percent of cases present with multi-vessel dissection?

Answer 4

20%

Question 5

What is the original presentation of these patients?

Answer 5

• Acute coronary syndrome (ACS)

- Sudden cardiac death (they just die from this)

Question 6

What is ESSENTIAL in the diagnosis of SCAD?

Answer 6

Early CORONARY ANGIOGRAPHY remains essential in the diagnosis

Question 7

What other types of imaging provide detailed information on the location and extent of the dissection?

Answer 7

• IVUS (Intravascular ultrasound)

- OCT (Optical coherence tomography)

Question 8

Describe the treatment of SCAD patients with ongoing myocardial ischemia

Answer 8

Pts w/ ongoing myocardial ischemia must be treated with early revascularization (PCI or CABG)

Question 9

Describe the treatment of SCAD patients with limited flow

Answer 9

Pts w/o flow limiting dissection should be treated conservatively as spontaneous healing is possible

Question 10

Do patients with SCAD typically have a high risk profile for coronary artery disease?

Answer 10

No - typically a low coronary risk profile

Not your typical 65 year old obese man with high cholesterol and a smoker

Question 11

Describe the clinical presentation

Answer 11

• Asymptomatic to unstable angina
• Acute MI
• Ventricular arrhythmias
• Sudden cardiac death
• Asymptomatic and discovered on angiogram

Question 12

Describe the diagnosis process

Answer 12

• Coronary Angiography
• Intracoronary imaging (IVUS, OCT, MDCT)
• These modalities have helped increase clinical recognition

Question 13

What would you see on a coronary angiography?

Answer 13

Presence of a thin longitudinal radiolucent line representing intimal medial flap with flow in 2 or more lumens

Question 14

What is the narrowing caused by?

Answer 14

Narrowing cause by the intramural hematoma imaging on the lumen can be misinterpreted as an atherosclerotic stenosis

Question 15

When should SCAD be suspected?

Answer 15

In the setting of young women presenting with ACS on angio and no CAD risk factors SCAD should be suspected and IVUS or OCT should be done

Question 16

What is the prognosis for patients in the hospital with SCAD?

Answer 16

In-hospital mortality of SCAD is relatively low

Mean rate of around 3% (0–4%)

Question 17

What is the lifetime prognosis for survivors of SCAD?

Answer 17

• Pts who survive the acute phase have a GOOD long term prognosis
• Low recurrence rate of SCAD or ACS and a 95% 2-year survival rate

Question 18

What is the overall mortality rate?

Answer 18

However, overall mortality in reported cases of postpartum group is 38%