Spontaneous coronary artery dissection diagnostic approach
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Spontaneous Coronary Artery Dissection Microchapters |
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Differentiating Spontaneous coronary artery dissection from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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Type 1 Type 2A Type 2B Type 3 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
Synonyms and keywords: SCAD
Overview
Coronary angiography is the standard for diagnosing spontaneous coronary artery dissection. Adjunctive imaging modalities such as intravascular ultrasonography (IVUS), optical coherence tomography (OCT), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) may offer complementary details for establishing a definitive diagnosis.
Algorithm for Diagnosis of Spontaneous Coronary Artery Dissection in the Setting of Acute Coronary Syndrome: A Scientific Statement From the American Heart Association
Algorithm for diagnosis of spontaneous coronary artery dissection (SCAD) in the setting of acute coronary syndrome.[1]
| Coronary angiography after intracoronary nitrates | |||||||||||||||||||||||||||||||||||||||
| Type 1 SCAD (arterial wall stain, multiple lumens) | Type 2 SCAD (intramural hematoma, diffuse, smooth stenoses) | Type 3 SCAD (mimics atherosclerosis) | |||||||||||||||||||||||||||||||||||||
| If diagnostic uncertainty, consider adjunctive diagnostic strategies: ❑ OCT/IVUS if feasible/safe ❑ CT coronary angiography ❑ CTA/MRA/angiographic imaging for extracoronary vasculopathy/FMD ❑ Repeat coronary angiography at 6–8 weeks | |||||||||||||||||||||||||||||||||||||||
Abbreviations:
CT, computed tomography;
CTA, computed tomography angiography;
FMD, fibromuscular dysplasia;
IVUS, intravascular ultrasonography;
MRA, magnetic resonance angiography;
OCT, optical coherence tomography.
Algorithm for Angiographic Diagnosis of Non-Atherosclerotic Spontaneous Coronary Artery Dissection
- A stepwise algorithm for diagnosing non-atherosclerotic SCAD has been proposed by Saw et al.[2]
- Clinicians should maintain a high index of suspicion for SCAD and consider early coronary angiography to ensure timely diagnosis and management.
- If the pathognomonic appearance of arterial wall stain with multiple radiolucent lumens is evident, then the diagnosis of type 1 SCAD can be established without additional intracoronary imaging.
- If type 1 SCAD appearance is not evident, angiographers should then assess for the presence of atherosclerotic changes in other coronary arteries, and consider intracoronary imaging if there is uncertainty as to non-atherosclerotic SCAD.
- For diffuse (>20 mm) and smooth stenosis of varying severity suggestive of type 2 SCAD, intracoronary nitroglycerin may be administered to rule out coronary spasm.
- If the stenosis remains unchanged after nitroglycerin administration, then optical coherence tomography (OCT) or intravascular ultrasound (IVUS) should be pursued.
- If there are concerns of compromising coronary flow with intracoronary imaging, then the stenosis could be reassessed in 4 to 6 weeks for hemodynamically stable patients, as SCAD typically resolves spontaneously.
Algorithm for the Angiographic Diagnosis and Confirmation of Spontaneous Coronary Artery Dissection[2]
Presence of features that raise suspicion for SCAD? ❑ Myocardial infarction in young women (age ≤50) ❑ Absence of traditional cardiovascular risk factors ❑ Little or no evidence of coronary atherosclerosis ❑ History of fibromuscular dysplasia ❑ History of connective tissue disorder or systemic inflammation ❑ Type 4 Ehlers-Danlos syndrome ❑ Systemic lupus erythematosus | |||||||||||||||||||||||||||||||
Perform early coronary angiography | |||||||||||||||||||||||||||||||
Presence of type 1 SCAD lesion characteristics? ❑ Contrast staining of arterial wall ❑ Multiple radiolucent lumens ❑ Contrast hang-up or slow clearing from the lumen | |||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||
Type 1 SCAD most likely | |||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||
Stenosis relieved by intracoronary nitroglycerin? | Look for type 3 SCAD lesion characteristics ❑ Focal or tubular stenosis (typically <20 mm) ❑ Mimics atherosclerosis ❑ Additional features ❑ No atherosclerosis in other arteries ❑ Long lesions (11–20 mm) | ||||||||||||||||||||||||||||||
YES | NO | Type 3 SCAD most likely ❑ Consider OCT or IVUS for definitive diagnosis ❑ Reassess with angiography in 4 to 6 weeks | |||||||||||||||||||||||||||||
R/O coronary spasm | Type 2 SCAD most likely ❑ Consider OCT or IVUS for definitive diagnosis ❑ Reassess with angiography in 4 to 6 weeks | ||||||||||||||||||||||||||||||
References
- ↑ Hayes, Sharonne N.; Kim, Esther S.H.; Saw, Jacqueline; Adlam, David; Arslanian-Engoren, Cynthia; Economy, Katherine E.; Ganesh, Santhi K.; Gulati, Rajiv; Lindsay, Mark E.; Mieres, Jennifer H.; Naderi, Sahar; Shah, Svati; Thaler, David E.; Tweet, Marysia S.; Wood, Malissa J. (2018). "Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association". Circulation: CIR.0000000000000564. doi:10.1161/CIR.0000000000000564. ISSN 0009-7322.
- ↑ 2.0 2.1 Saw J (2014). "Coronary angiogram classification of spontaneous coronary artery dissection". Catheter Cardiovasc Interv. 84 (7): 1115–22. doi:10.1002/ccd.25293. PMID 24227590.