|
|
| Line 1: |
Line 1: |
| {{short description|uncommon cause of heart attacks mostly affecting younger, healthy women}} | | {{Short description|A rare condition involving a tear in a coronary artery}} |
| {{Infobox medical condition (new) | | {{Use dmy dates|date=October 2023}} |
| | name = Spontaneous coronary artery dissection
| |
| | synonyms = Coronary artery dissection
| |
| | image = RevisedSCAD.png
| |
| | caption = Coronary artery dissection involves the formation of a hematoma (purple) within the walls of the coronary artery.
| |
| | pronounce =
| |
| | field =
| |
| | symptoms =
| |
| | complications =
| |
| | onset =
| |
| | duration =
| |
| | types =
| |
| | causes =
| |
| | risks =
| |
| | diagnosis =
| |
| | differential =
| |
| | prevention =
| |
| | treatment =
| |
| | medication =
| |
| | prognosis = | |
| | frequency =
| |
| | deaths =
| |
| }} | |
| '''Spontaneous coronary artery dissection''' ('''SCAD''') is an uncommon but dangerous condition in which one of the [[coronary arteries|arteries]] that supply the heart spontaneously develops a blood collection, or [[hematoma]], within the artery wall. This leads to a [[Dissection (medical)|separation and weakening of the walls of the artery]].
| |
|
| |
|
| SCAD is a major cause of [[heart attack]]s in young, otherwise healthy women without known risk factors. While the exact cause is not yet known, SCAD is likely related to changes that occur during and after pregnancy, as well as other diseases. These changes lead to the dissection of the wall which restricts blood flow to the heart and causes symptoms. SCAD is often diagnosed in the [[cath lab]] with [[angiography]], though more advanced confirmatory tests exist. While the risk of death due to SCAD is low, it has a relatively high rate of recurrence leading to further heart attack-like symptoms in the future. It was first described in 1931.<ref name="Pretty1931">{{cite journal |vauthors=Pretty HC |title=Dissecting aneurysm of coronary artery in a woman aged 42 |journal=British Medical Journal |volume=1 |issue=3667 |page=667 |date=18 April 1931 |doi=10.1136/bmj.1.3667.667}}</ref> | | '''Spontaneous coronary artery dissection''' ('''SCAD''') is a rare but serious condition that occurs when a tear forms in one of the [[coronary arteries]], which supply blood to the [[heart]]. This tear can cause blood to flow between the layers of the artery wall, leading to a blockage that can result in a [[myocardial infarction]] (heart attack), [[arrhythmia]], or sudden cardiac death. |
| | |
| ==Signs and symptoms==
| |
| SCAD often presents like a [[heart attack]] in young to middle-aged, healthy women.<ref> [http://www.invasivecardiology.com/article/3062 "Spontaneous Coronary Artery Dissection Postpartum"]</ref> This pattern usually includes chest pain, rapid heartbeat, shortness of breath, sweating, extreme tiredness, nausea, and dizziness.<ref>{{Cite web|url=https://www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/symptoms-causes/syc-20353711?p=1|title=Symptoms and causes - Mayo Clinic|website=www.mayoclinic.org|language=en|access-date=2018-11-07}}</ref> A minority of people with SCAD may also present in [[cardiogenic shock]] (2-5%), [[ventricular arrhythmias]] (3-11%), or after [[sudden cardiac death]].<ref name=aha18>{{cite journal |last1=Hayes |first1=Sharonne N. |last2=Kim |first2=Esther S.H. |last3=Saw |first3=Jacqueline |last4=Adlam |first4=David |last5=Arslanian-Engoren |first5=Cynthia |last6=Economy |first6=Katherine E. |last7=Ganesh |first7=Santhi K. |last8=Gulati |first8=Rajiv |last9=Lindsay |first9=Mark E. |last10=Mieres |first10=Jennifer H. |last11=Naderi |first11=Sahar |last12=Shah |first12=Svati |last13=Thaler |first13=David E. |last14=Tweet |first14=Marysia S. |last15=Wood |first15=Malissa J. |title=Spontaneous Coronary Artery Dissection: Current State of the Science |journal=Circulation |volume=137 |issue=19 |pages=e523–e557 |doi=10.1161/CIR.0000000000000564 |pmid=29472380 |pmc=5957087 |date=8 May 2018}}</ref> Pregnancy- and postpartum-associated SCAD generally have worse outcomes compared to other cases.<ref name=aha18 />
| |
| | |
| ==Causes==
| |
| Risk factors include pregnancy and the [[postpartum]] period. Evidence suggests that [[estrogen]]- and [[progesterone]]-related vascular changes affect the coronary arteries during this period, contributing to SCAD.<ref name=aha18 /> Some case reports and case series suggest associations with autoimmune inflammatory diseases, but there have not been larger studies to explore this relationship.<ref name=aha18 /> Underlying heritable conditions such as [[fibromuscular dysplasia]] and connective-tissue disorders (e.g., [[Marfan syndrome]], [[Ehlers–Danlos syndrome]], and [[Loeys–Dietz syndrome]]) are associated with SCAD,<ref>Dhawan R, Singh G, Fesniak H. (2002) "Spontaneous coronary artery dissection: the clinical spectrum". ''Angiology''</ref> but SCAD otherwise lacks a significant genetic component.<ref name=aha18 /> SCAD triggers may include severe physical or emotional stress, but many cases have no obvious cause.<ref>Mark V. Sherrid; Jennifer Mieres; Allen Mogtader; Naresh Menezes; Gregory Steinberg (1995) "Onset During Exercise of Spontaneous Coronary Artery Dissection and Sudden Death. Occurrence in a Trained Athlete: Case Report and Review of Prior Cases" ''Chest''</ref><ref>{http://www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/basics/risk-factors/con-20037794}</ref>
| |
|
| |
|
| ==Pathophysiology== | | ==Pathophysiology== |
| SCAD symptoms are the result of a restriction in the size of the affected coronary artery. The dissection leads to a collection of blood, or [[hematoma]], between the layers of the artery wall. The hematoma does not carry oxygen to the heart muscle but instead forms a "false [[lumen (anatomy)|lumen]]" that restricts the flow of blood through the "true lumen" to the heart muscle. As yet, there is no consensus on why the hematoma develops in the first place.<ref>Virmani R, Forman MB, Rabinowitz M, McAllister HA (1984) "Coronary artery dissections" ''Cardiol Clinics''</ref><ref>Kamineni R, Sadhu A, Alpert JS. (2002) "Spontaneous coronary artery dissection: Report of two cases and 50-year review of the literature" ''Cardiol Rev''</ref><ref name="pmid18830003">{{cite journal | vauthors = Kamran M, Guptan A, Bogal M | title = Spontaneous coronary artery dissection: case series and review | journal = The Journal of Invasive Cardiology | volume = 20 | issue = 10 | pages = 553–9 | date = October 2008 | pmid = 18830003 }}</ref> | | SCAD involves a separation of the layers of the coronary artery wall, which can create a false lumen. Blood entering this false lumen can compress the true lumen, reducing or obstructing blood flow to the heart muscle. The exact cause of SCAD is not well understood, but it is believed to involve a combination of factors including [[hormonal changes]], [[connective tissue disorders]], and [[inflammatory conditions]]. |
| | |
| The restriction limits the availability of oxygen and nutrients to the heart muscle, or [[myocardium]]. As a result, the myocardium continues to demand oxygen but is not adequately supplied by the coronary artery. This imbalance leads to [[ischemia]], damage, and eventually death of myocardium, causing a heart attack ([[myocardial infarction]]). Heart attacks can classically present as chest pain or pressure, shortness of breath, pain in the [[epigastrium|upper abdomen]], and a radiating pain extending along the left arm or the left side of the neck.
| |
| | |
| ==Diagnosis==
| |
| [[File:Coronarographie.gif|thumb|This is a representative video of coronary angiography. While it does not display SCAD, it highlights the technique used to identify the condition.]]
| |
| Given the demographics of SCAD, it is important to maintain a high index of suspicion for the condition in otherwise low-risk women presenting with symptoms of [[acute coronary syndrome]]. Initial evaluation may show [[ECG]] changes of ST elevation, like heart attacks due to other causes. SCAD comprises 2-4% of all cases of acute coronary syndrome.<ref name=macaya18>{{cite journal |last1=Macaya |first1=Fernando |last2=Salinas |first2=Pablo |last3=Gonzalo |first3=Nieves |last4=Fernández-Ortiz |first4=Antonio |last5=Macaya |first5=Carlos |last6=Escaned |first6=Javier |title=Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management |journal=Open Heart |volume=5 |issue=2 |pages=e000884 |doi=10.1136/openhrt-2018-000884 |pmid=30487978 |pmc=6241978 |date=5 November 2018}}</ref>
| |
| | |
| With typically elevated cardiac biomarkers and ECG changes, people will often undergo [[coronary angiography]] evaluation.<ref name=aha18 /><ref>C. Basso, G. L. Morgagni, G. Thiene (1996) "Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death" ''BMJ''</ref><ref name="pmid1449336">{{cite journal | vauthors = Desseigne P, Tabib A, Loire R | title = [An unusual cause of sudden death: spontaneous dissection of coronary arteries. Apropos of 2 cases] | journal = Archives des Maladies du Coeur et des Vaisseaux | volume = 85 | issue = 7 | pages = 1031–3 | date = July 1992 | pmid = 1449336 }}</ref> It is important to recognize SCAD through angiography as other confirmatory measures carry increased risks.<ref name = franke19/>
| |
| | |
| === Angiography ===
| |
| Angiographic appearances of SCAD fall into three categories.<ref name=macaya18 /> Type 1 lesions appear as classic angiographic [[dissections]], with a false [[Lumen (anatomy)|lumen]] distinct from the true lumen. These are the easiest to identify as SCAD clinically, though relatively uncommon.<ref name=macaya18 /> Type 2 lesions - the most common subtype of SCAD - appear as a long, smooth narrowing of the vessel without a distinctly visible false and true lumen.<ref name=aha18 /> Type 3 lesions appear similar to atherosclerotic lesions and are difficult to confirm as SCAD through angiography alone,<ref name = franke19/> possibly requiring the use of intracoronary imaging.
| |
| | |
| === Intracoronary imaging ===
| |
| [[File:Ivus&oct.png|thumb|upright=1.3|This is a representative image of two types of intracoronary imaging, OCT (left) and IVUS (right).]]
| |
| Intracoronary imaging (ICI), consisting of [[intracoronary optical coherence tomography]] (OCT) and [[intravascular ultrasound]] (IVUS) can help distinguish SCAD from an [[Atherosclerosis|atherosclerotic lesion]] when it is difficult to do so with angiography.<ref name="Ultrasound">[http://www.medscape.com/viewarticle/471327_6 Intravascular Ultrasound Imaging in the Diagnosis and Treatment: The Future: IVUS-Guided DES Implantation?]</ref> ICI techniques provide a direct view of the walls of the coronary artery to confirm SCAD, but may actually worsen the dissection as the probes are inserted into the damaged area.<ref name=aha18 /> ICI confers a 3.4% risk of [[iatrogenic]] dissection in people with SCAD compared to 0.2% risk in the general population.<ref name=aha18 /> Between the two ICI methods, OCT - a newer technique - has superior spatial resolution than IVUS and is the preferred technique if ICI is required,<ref name=aha18 /> but the need to inject extra contrast with OCT poses risk for worsening the dissection.<ref name=macaya18 />
| |
| | |
| === Other methods ===
| |
| Some studies propose [[coronary CT angiography]] to evaluate SCAD in lower-risk people, with research into the approach ongoing.<ref name=aha18 /><ref name = franke19/>
| |
| | |
| == Management ==
| |
| Management depends upon the presenting symptoms. In most people who are hemodynamically stable without high-risk coronary involvement, conservative medical management with blood pressure control is recommended.<ref name =aha18 /><ref>{{Cite web|url=https://www.heart.org/en/health-topics/heart-attack/about-heart-attacks/coronary-artery-dissection-not-just-a-heart-attack|title=Coronary Artery Dissection: Not Just a Heart Attack|website=www.heart.org|language=en|access-date=2018-11-07}}</ref><ref>{{Cite web|url=https://www.cardiovascularbusiness.com/topics/coronary-intervention-surgery/scad-not-your-typical-heart-attack-new-findings-increased|title=SCAD: Not Your Typical Heart Attack|last=|first=|date=|website=|url-status=live|archive-url=|archive-date=|access-date=}}</ref> In these people, especially if angiography demonstrates adequate coronary flow, the most likely course usually leads to spontaneous healing, often within 30 days.<ref name="pmid23078737">{{cite journal | vauthors = Alfonso F, Paulo M, Lennie V, Dutary J, Bernardo E, Jiménez-Quevedo P, Gonzalo N, Escaned J, Bañuelos C, Pérez-Vizcayno MJ, Hernández R, Macaya C | title = Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy | journal = JACC. Cardiovascular Interventions | volume = 5 | issue = 10 | pages = 1062–70 | date = October 2012 | pmid = 23078737 | doi = 10.1016/j.jcin.2012.06.014 | doi-access = free }}</ref>
| |
| | |
| In cases involving high-risk coronaries, hemodynamic instability, or a lack of improvement or worsening after initial attempts at treatment, urgent treatment with [[coronary stent]]s or [[coronary artery bypass surgery]] may be necessary.<ref name = franke19/> Stents carry the risk of worsening the dissection or have an increased risk of other complications as the vessel walls in SCAD are already weak due to the disease before introducing the stent.<ref name =aha18 /> Large studies into coronary artery bypass surgery are lacking, but this approach is used to redirect blood to the heart around the affected area for cases involving the [[left main coronary artery]] or when other approaches fail.<ref name =aha18 /><ref>[http://www.medhelp.org/posts/Heart-Disease/Coronary-artery-dissection-treatment/show/866971 MedHelp:Coronary artery dissection treatment]</ref><ref name="pmid25406203">{{cite journal | vauthors = Tweet MS, Eleid MF, Best PJ, Lennon RJ, Lerman A, Rihal CS, Holmes DR, Hayes SN, Gulati R | title = Spontaneous coronary artery dissection: revascularization versus conservative therapy | journal = Circulation: Cardiovascular Interventions | volume = 7 | issue = 6 | pages = 777–86 | date = December 2014 | pmid = 25406203 | doi = 10.1161/CIRCINTERVENTIONS.114.001659 | doi-access = free }}</ref>
| |
| | |
| After addressing the SCAD, people are often treated with typical post-heart attack care, though people who are pregnant may need altered therapy due to the possibility of some [[teratogenic]] cardiac medications affecting [[fetal development]].<ref name = franke19/> Depending on the clinical situation, providers may screen for associated connective tissue diseases.<ref name = franke19/>
| |
| | |
| == Prognosis ==
| |
| | |
| People with SCAD have a low in-hospital mortality after treatment. However, the lesion may worsen after leaving the hospital within the first month.<ref name=franke19 /><ref name=janssen19 /> One study suggested a 1.2% mortality rate following SCAD but a 19.9% risk for either death, heart attacks, or strokes.<ref>{{cite journal |last1=Saw |first1=Jacqueline |last2=Humphries |first2=Karin |last3=Aymong |first3=Eve |last4=Sedlak |first4=Tara |last5=Prakash |first5=Roshan |last6=Starovoytov |first6=Andrew |last7=Mancini |first7=G. B. John |title=Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence |volume=70 |issue=9 |journal=Journal of the American College of Cardiology |pages=1148–1158 |doi=10.1016/j.jacc.2017.06.053 |pmid=28838364 |date=29 August 2017|doi-access=free }}</ref> Even afterwards, SCAD has a high recurrence risk at 30% within 10 years, often at a different site than the initial lesion - meaning that stents placed in the location of the first lesion may not protect against a second.<ref name=franke19 /> Given the lack of consensus on the cause of SCAD, prevention of future SCAD may include medical therapy, counseling about becoming pregnant again (for those who had pregnancy-associated SCAD), or avoidance of [[oral contraceptives]] - as they contain estrogen and progesterone.
| |
|
| |
|
| ==Epidemiology== | | ==Epidemiology== |
| SCAD is the most common cause of [[heart attacks]] in pregnant and [[postpartum]] women. Over 90% of people who develop SCAD are women.<ref name=janssen19>{{cite journal |last1=Janssen |first1=E. B. N. J. |last2=de Leeuw |first2=P. W. |last3=Maas |first3=A. H. E. M. |title=Spontaneous coronary artery dissections and associated predisposing factors: a narrative review |journal=Netherlands Heart Journal |volume=27 |issue=5 |pages=246–251 |doi=10.1007/s12471-019-1235-4 |pmid=30684142 |pmc=6470242 |date=2019}}</ref> It is especially common among women aged 43–52.<ref name=franke19>{{cite journal |last1=Franke |first1=Kyle B. |last2=Wong |first2=Dennis T. L. |last3=Baumann |first3=Angus |last4=Nicholls |first4=Stephen J. |last5=Gulati |first5=Rajiv |last6=Psaltis |first6=Peter J. |title=Current state-of-play in spontaneous coronary artery dissection |journal=Cardiovascular Diagnosis and Therapy |volume=9 |issue=3 |pages=281–298 |doi=10.21037/cdt.2019.04.03 |pmid=31275818 |pmc=6603494 |date=2019}}</ref> With angiography and improved recognition of the condition, diagnosis of SCAD has improved since the early 2010s. While prior studies had reported a SCAD prevalence of less than 1% in patients presenting with acute coronary syndrome, more recent data suggests the prevalence of SCAD in acute coronary syndrome patients may be between 2-4%.<ref name=saw16>{{cite journal |last1=Saw |first1=Jacqueline |last2=Mancini |first2=G. B. John |last3=Humphries |first3=Karin H. |title=Contemporary Review on Spontaneous Coronary Artery Dissection |url=http://www.onlinejacc.org/content/68/3/297.abstract |journal=Journal of the American College of Cardiology |volume=68 |issue=3 |pages=297–312 |language=en |doi=10.1016/j.jacc.2016.05.034 |pmid=27417009 |date=19 July 2016|doi-access=free }}</ref> | | SCAD is more common in women, particularly those under the age of 50. It is a significant cause of [[acute coronary syndrome]] in young women and is often associated with pregnancy or the postpartum period. However, it can also occur in men and older individuals. |
|
| |
|
| ==History== | | ==Clinical Presentation== |
| SCAD was first described in the year 1931, at postmortem examination, in a 42-year-old woman.<ref name="Pretty1931"/><ref name=saw16 /> Due to a lack of recognition and diagnostic technology though, SCAD literature until the 21st century included only case reports and series.<ref name=saw16 /> With the recent advent of coronary angiography and intracoronary imaging, recognition and diagnosis of SCAD has greatly increased, especially in the 2010s.<ref name=saw16 /> | | Patients with SCAD typically present with symptoms of acute coronary syndrome, such as chest pain, shortness of breath, and [[nausea]]. The condition can mimic other forms of [[ischemic heart disease]], making diagnosis challenging. Electrocardiograms (ECGs) and cardiac biomarkers are often used in the initial assessment. |
|
| |
|
| == See also == | | ==Diagnosis== |
| * [[Dissection (medical)]]
| | The diagnosis of SCAD is usually confirmed through [[coronary angiography]], which can reveal the characteristic appearance of a dissection. Intravascular imaging techniques such as [[intravascular ultrasound]] (IVUS) or [[optical coherence tomography]] (OCT) may be used to provide more detailed information about the dissection. |
| * [[Aortic dissection]], a similar condition affecting a different artery
| |
| * [[Kounis syndrome]]
| |
|
| |
|
| == References == | | ==Management== |
| {{Reflist}}
| | The management of SCAD focuses on restoring blood flow to the affected area of the heart and preventing further complications. Treatment options may include conservative management, [[percutaneous coronary intervention]] (PCI), or [[coronary artery bypass grafting]] (CABG), depending on the severity of the dissection and the patient's clinical condition. Medications such as [[beta-blockers]], [[antiplatelet agents]], and [[statins]] may also be prescribed. |
|
| |
|
| == External links == | | ==Prognosis== |
| {{Medical resources
| | The prognosis for patients with SCAD varies. Many patients recover with appropriate treatment, but there is a risk of recurrence. Long-term follow-up and lifestyle modifications are important components of care. |
| | DiseasesDB = 3115
| |
| | ICD10 = {{ICD10|I|25|4|i|20}}
| |
| | ICD9 = {{ICD9|414.12}}
| |
| | ICDO =
| |
| | OMIM =
| |
| | MedlinePlus =
| |
| | eMedicineSubj =
| |
| | eMedicineTopic =
| |
| | MeshID =
| |
| }}
| |
| *[http://www.invasivecardiology.com/article/3062 "Spontaneous Coronary Artery Dissection Postpartum"]
| |
| *[http://www.invasivecardiology.com/articles/Spontaneous-Coronary-Artery-Dissection-Case-Series-and-Review "Spontaneous-Coronary-Artery-Dissection-Case-Series-and-Review"]
| |
|
| |
|
| {{Heart diseases}}
| | ==Related pages== |
| | * [[Coronary artery disease]] |
| | * [[Myocardial infarction]] |
| | * [[Acute coronary syndrome]] |
| | * [[Cardiology]] |
|
| |
|
| {{DEFAULTSORT:Coronary Artery Dissection}}
| | [[Category:Cardiology]] |
| [[Category:Diseases of the aorta]] | | [[Category:Vascular diseases]] |
| [[Category:Heart diseases]] | | [[Category:Medical emergencies]] |
| [[Category:Causes of death]] | |
| {{dictionary-stub1}}
| |
A rare condition involving a tear in a coronary artery
Spontaneous coronary artery dissection (SCAD) is a rare but serious condition that occurs when a tear forms in one of the coronary arteries, which supply blood to the heart. This tear can cause blood to flow between the layers of the artery wall, leading to a blockage that can result in a myocardial infarction (heart attack), arrhythmia, or sudden cardiac death.
Pathophysiology
SCAD involves a separation of the layers of the coronary artery wall, which can create a false lumen. Blood entering this false lumen can compress the true lumen, reducing or obstructing blood flow to the heart muscle. The exact cause of SCAD is not well understood, but it is believed to involve a combination of factors including hormonal changes, connective tissue disorders, and inflammatory conditions.
Epidemiology
SCAD is more common in women, particularly those under the age of 50. It is a significant cause of acute coronary syndrome in young women and is often associated with pregnancy or the postpartum period. However, it can also occur in men and older individuals.
Clinical Presentation
Patients with SCAD typically present with symptoms of acute coronary syndrome, such as chest pain, shortness of breath, and nausea. The condition can mimic other forms of ischemic heart disease, making diagnosis challenging. Electrocardiograms (ECGs) and cardiac biomarkers are often used in the initial assessment.
Diagnosis
The diagnosis of SCAD is usually confirmed through coronary angiography, which can reveal the characteristic appearance of a dissection. Intravascular imaging techniques such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) may be used to provide more detailed information about the dissection.
Management
The management of SCAD focuses on restoring blood flow to the affected area of the heart and preventing further complications. Treatment options may include conservative management, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG), depending on the severity of the dissection and the patient's clinical condition. Medications such as beta-blockers, antiplatelet agents, and statins may also be prescribed.
Prognosis
The prognosis for patients with SCAD varies. Many patients recover with appropriate treatment, but there is a risk of recurrence. Long-term follow-up and lifestyle modifications are important components of care.
Related pages
