Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized etiology of acute coronary syndrome (ACS) and an important cause of myocardial infarction in women. First described in 1931, SCAD is defined as a spontaneous tear in a coronary artery that is not associated with atherosclerosis, trauma or medical intervention. SCAD predominantly affects younger women, who often lack atherosclerotic risk factors. Some risk factors that have been identified include female sex, pregnancy, severe emotional or physical stress, underlying blood vessel diseases such as fibromuscular dysplasia, and connective tissue diseases such as Ehlers-Danlos syndrome or Marfan syndrome. Previously believed to be rare, a chiefly fatal condition, recent epidemiological data suggests SCAD is accountable for up to 4 % of all ACS cases and up to 35 % of ACS cases in women < 50 years of age. There is a lack of awareness of SCAD among physicians, which probably results in underreporting and underdiagnosing of this disorder. The clinical presentation of SCAD is often similar to that of ACS making differentiation at first presentation difficult. Cardiac enzymes are elevated like in ACS and there are no biomarkers that are specific for the diagnosis of SCAD. Coronary angiography is the gold standard method to distinguish both entities, however correct diagnosis by cath is challenging and SCAD can be truly missed and misdiagnosed as classic ACS. Still there are no randomized controlled trials about the optimal treatment of these patients. But it is suggested that management should be different to atherosclerotic myocardial infarction. Conservative medical treatment is favored in the majority of cases, with percutaneous coronary intervention (PCI) being reserved for high risk patients due to poor interventional outcomes and higher failure rates. However, there is still a lack of data on this poorly understood condition and the optimal management has yet to be determined.