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Figures
- Figure 1:
A 50-year-old woman presented with ST elevation myocardial infarction (MI) secondary to spontaneous coronary artery dissection. Electrocardiogram from initial presentation showing ST elevation in the anterior precordial leads with associated Q-waves compatible with acute MI (arrows).
- Figure 2:
(A) Coronary angiography at initial presentation showing the dominant right coronary artery in the anterior–posterior cranial projection, revealing no luminal irregularities. Tortuosity of the posterior interventricular branch is noted (asterisks). (B) Coronary angiography of the left coronary artery in the right anterior oblique (RAO)–caudal projection at initial presentation. Arrows indicate luminal narrowing of the distal left main artery extending 20 mm into the proximal left anterior descending (LAD) artery. Asterisks indicate tortuosity of the left circumflex artery. (C) Coronary angiography of the left coronary artery in the RAO–cranial projection at initial presentation. Arrows indicate luminal narrowing of the distal left main and proximal LAD coronary arteries. (D) Repeat coronary angiography of the left coronary artery in the RAO–caudal projection, performed 2 weeks after initial presentation for recurrent chest pain. Arrows show angiographic resolution of the left main and proximal LAD artery dissection.
- Figure 3:
Optical coherence tomography (OCT) images of (A) the normal distal left anterior descending (LAD) artery, revealing the true lumen (TL), normal coronary artery wall (N) and OCT imaging catheter (cath.); (B) the dissected proximal LAD artery with both TL and false lumen (FL) and the OCT imaging catheter (cath.) — notably, the FL contains the intramural hematoma; and (C) the dissected proximal LAD artery, showing both the TL and the FL that is causing 50%–80% narrowing of the TL by extrinsic compression over this segment.
Tables
- Table 1:
Key differences in the demographics, associated conditions and management of spontaneous coronary artery dissection compared with atherosclerotic acute coronary syndrome
Characteristic SCAD Atherosclerotic ACS Demographics Sex More frequent in women More frequent in men Hypertension Less common Common Dyslipidemia Less common Common Smoking Less common Common Pregnancy Common Uncommon Emotional or physical stress Common Uncommon Migraines Common Uncommon FMD Common Uncommon Revascularization PCI (balloon angioplasty with or without stenting) Conservative strategy
Consider PCI if hemodynamically unstable, large territory or multiple coronary arteries with SCAD
Recommended Coronary artery bypass graft When PCI is not possible When PCI is not possible Medical therapy Antiplatelet agents Lack of evidence to guide therapy
Dual antiplatelet therapy for 1 year if a stent is placed
In the absence of stent implantation, use of single v. dual antiplatelet therapy is controversial
Dual antiplatelet therapy for 1 year β-blockers Recommended Recommended ACE inhibitors No clear benefit Recommended ARBs No clear benefit Recommended Statins No clear benefit Recommended Lifestyle Diet No restrictions Healthy heart diet Physical activity Moderate intensity exercise Exercise intensity as tolerated Stress management Recommended Recommended Smoking cessation Recommended Recommended Additional screening FMD screening Computed tomography angiogram from head to pelvis recommended Not required Note: ACE = angiotensin-converting-enzyme, ACS = acute coronary syndrome, ARB = angiotensin II receptor blocker, FMD = fibromuscular dysplasia, PCI = percutaneous coronary intervention, SCAD = spontaneous coronary artery dissection.
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