Spontaneous coronary artery dissection treatment approach: Difference between revisions
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{{SK}} SCAD | {{SK}} SCAD | ||
==Overview== | ==Overview== | ||
Long-term treatment for spontaneous coronary artery dissection pursues several main goals including antianginal therapy, prevention of recurrence, assessment, and management of extra coronary [[vascular]] abnormalities, and improvement of quality of life. | Acute management of [[myocardial infarction]] in [[SCAD]] is [[medical therapy]] in approximately 80% of the [[patients]]. [[Myocardial infarction]] in the context of [[SCAD]] is different from the [[myocardial infarction]] in the context of [[atherosclerosis]] and therefore makes it unfavorable for [[revascularization]] approaches. Long-term treatment for [[spontaneous coronary artery dissection]] pursues several main goals including [[antianginal]] therapy, prevention of [[recurrence]], assessment, and management of extra [[coronary]] [[vascular]] abnormalities, and improvement of [[quality of life]]. To improve the quality of life in [[patients]] with [[SCAD]], consider [[cardiac rehabilitation]] referral and manage [[patients]] [[comorbidities]]. | ||
==Algorithm for management of acute spontaneous coronary artery dissection: A Scientific Statement From the American Heart Association== | ==Algorithm for management of acute spontaneous coronary artery dissection: A Scientific Statement From the American Heart Association== | ||
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{{Familytree/start}} | {{Familytree/start}} | ||
{{Familytree | | | | | | | | | A01 | | | | | | | | |A01=<div style="text-align: left; padding: 5px;">'''Management of Acute Spontaneous Coronary Artery Dissection'''</div>}} | {{Familytree | | | | | | | | | A01 | | | | | | | | |A01=<div style="text-align: left; padding: 5px;">'''Management of [[Acute]] [[Spontaneous Coronary Artery Dissection]]'''</div>}} | ||
{{Familytree | | | |,|-|-|-|-|-|+|-|-|-|-|-|.| | | |}} | {{Familytree | | | |,|-|-|-|-|-|+|-|-|-|-|-|.| | | |}} | ||
{{Familytree | | | B01 | | | | B02 | | | | B03 | | |B01='''Clinically stable <BR>without high-risk anatomy'''|B02='''Clinically stable with high-risk anatomy'''<BR>'''(i.e., left main or proximal 2-vessel dissection)'''|B03='''Active/ongoing ischemia <BR>or hemodynamic instability'''}} | {{Familytree | | | B01 | | | | B02 | | | | B03 | | |B01='''Clinically stable <BR>without high-risk [[anatomy]]'''|B02='''Clinically stable with high-risk [[anatomy]]'''<BR>'''(i.e., [[left main]] or [[proximal]] 2-vessel [[dissection]])'''|B03='''Active/[[ongoing ischemia]] <BR>or [[hemodynamic instability]]'''}} | ||
{{Familytree | | | |!| | | | | |!| | | | | |!| | | |}} | {{Familytree | | | |!| | | | | |!| | | | | |!| | | |}} | ||
{{Familytree | | | C01 | | | | C02 | | | | C03 | | |C01=<div style="text-align: left; padding: 5px;">❑ Conservative therapy<BR>❑ Monitor as inpatient 3–5 days</div>|C02=<div style="text-align: left; padding: 5px;">❑ Consider CABG<BR>❑ Conservative Rx may be reasonable</div>|C03=<div style="text-align: left; padding: 5px;">❑ Consider PCI if feasible, OR<BR>❑ Urgent CABG (based on technical considerations and local expertise)</div>}} | {{Familytree | | | C01 | | | | C02 | | | | C03 | | |C01=<div style="text-align: left; padding: 5px;">❑ Conservative therapy<BR>❑ Monitor as [[inpatient]] 3–5 days</div>|C02=<div style="text-align: left; padding: 5px;">❑ Consider [[CABG]]<BR>❑ Conservative Rx may be reasonable</div>|C03=<div style="text-align: left; padding: 5px;">❑ Consider [[PCI]] if feasible, OR<BR>❑ Urgent [[CABG]] (based on technical considerations and local expertise)</div>}} | ||
{{Family tree/end}} | {{Family tree/end}} | ||
<span style="font-size: 100%;"> | <span style="font-size: 100%;"> | ||
'''Abbreviations''': | '''Abbreviations''': | ||
CABG, coronary artery bypass grafting; | [[CABG]], [[coronary artery bypass grafting]]; | ||
PCI, percutaneous coronary intervention; | [[PCI]], [[percutaneous coronary intervention]]; | ||
Rx, management. | Rx, management. | ||
</span> | </span> | ||
</div> | </div> | ||
==Acute Management== | ==Acute Management== | ||
*Acute management of [[myocardial infarction]] in SCAD is medical therapy in approximately 80% of the [[patients]]. [[Myocardial infarction]] in the context of SCAD is different from the [[myocardial infarction]] in the context of [[atherosclerosis]] and therefore makes it unfavorable for [[revascularization]] approaches.<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | *Acute management of [[myocardial infarction]] in [[SCAD]] is [[medical therapy]] in approximately 80% of the [[patients]]. [[Myocardial infarction]] in the context of [[SCAD]] is different from the [[myocardial infarction]] in the context of [[atherosclerosis]] and therefore makes it unfavorable for [[revascularization]] approaches.<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
*[[ | *[[Percutaneous coronary intervention]] ([[PCI]]) can be considered in high risk [[patients]], such as: | ||
**[[Patients]] with following clinical presentations: | **[[Patients]] with following clinical presentations: | ||
***Persistent [[chest pain]] with evidence of worsening [[ischemia]] | ***Persistent [[chest pain]] with evidence of worsening [[ischemia]] | ||
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***[[Ventricular]] [[arrhythmias]] | ***[[Ventricular]] [[arrhythmias]] | ||
**[[Patients]] with following [[vascular]] involvement: | **[[Patients]] with following [[vascular]] involvement: | ||
*** | ***Multi-vessel proximal dissections | ||
***Left main artery dissection | ***[[Left main artery]] dissection | ||
***Ostial left anterior descending artery dissection | ***Ostial [[left anterior descending]] [[artery]] [[dissection]] | ||
*Management with PCI may be associated with several adverse events, including: | *Management with [[PCI]] may be associated with several adverse events, including: | ||
** [[Stent]] malposition | |||
** Iatrogenic injury to the [[vessels]] | |||
** [[Hematoma]] | |||
** [[ Coronary]] [[vessel]] occlusion | |||
** [[Coronary]] [[vessel]] anomaly | |||
==Long-Term Treatment Approach== | ==Long-Term Treatment Approach== | ||
* Long-term treatment for spontaneous coronary artery dissection pursues several main goals:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | * Long-term treatment for spontaneous [[coronary artery]] dissection pursues several main goals:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
**Antianginal therapy | **[[Antianginal]] therapy | ||
**Prevention of recurrence | **Prevention of recurrence | ||
**Assessment and management of extra coronary [[vascular]] abnormalities | **Assessment and management of extra [[coronary]] [[vascular]] abnormalities | ||
**Improvement of quality of life | **Improvement of [[quality of life]] | ||
===Management of [[Chest Pain]]=== | ===Management of [[Chest Pain]]=== | ||
* To manage of [[chest pain]] in [[patients]] with SCAD consider the followings:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | * To manage of [[chest pain]] in [[patients]] with [[SCAD]] consider the followings:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
** Antianginal [[medications]] | ** [[Antianginal]] [[medications]] | ||
** Consider further testing to rule out underlying [[ischemia]] | ** Consider further testing to rule out underlying [[ischemia]] | ||
** Consider other possible diagnoses | ** Consider other possible diagnoses | ||
===Prevention=== | ===Prevention=== | ||
* To reduce the risk of SCAD recurrence, the following should be considered:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | * To reduce the risk of [[SCAD]] recurrence, the following should be considered:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
** [[Beta-blocker]] therapy | ** [[Beta-blocker]] therapy | ||
** Management of [[hypertension]] | ** Management of [[hypertension]] | ||
** Maintaining physical activity | ** Maintaining [[physical activity]] | ||
===Assessment of [[Vascular]] Abnormalities=== | ===Assessment of [[Vascular]] Abnormalities=== | ||
* To identify [[patients]] with SCAD-associated conditions, [[imaging]] with [[CT angiography]] or [[magnetic resonance angiography]] is recommended.<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | * To identify [[patients]] with [[SCAD]]-associated conditions, [[imaging]] with [[CT angiography]] or [[magnetic resonance angiography]] is recommended.<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
===Improvement in Quality of life=== | ===Improvement in Quality of life=== | ||
* To improve the quality of life in [[patients]] with SCAD, consider:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | * To improve the quality of life in [[patients]] with [[SCAD]], consider:<ref name="KimLongo2020">{{cite journal|last1=Kim|first1=Esther S.H.|last2=Longo|first2=Dan L.|title=Spontaneous Coronary-Artery Dissection|journal=New England Journal of Medicine|volume=383|issue=24|year=2020|pages=2358–2370|issn=0028-4793|doi=10.1056/NEJMra2001524}}</ref> | ||
**[[Cardiac rehabilitation]] referral | **[[Cardiac rehabilitation]] referral | ||
** Manage patients comorbidities | ** Manage [[patients]] [[comorbidities]] | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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[[Category:Angiographic Definitions]] | [[Category:Angiographic Definitions]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Up-To-Date]] | |||
Latest revision as of 17:59, 16 April 2021
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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: Sahar Memar Montazerin, M.D.[2] Nate Michalak, B.A.
Synonyms and keywords: SCAD
Overview
Acute management of myocardial infarction in SCAD is medical therapy in approximately 80% of the patients. Myocardial infarction in the context of SCAD is different from the myocardial infarction in the context of atherosclerosis and therefore makes it unfavorable for revascularization approaches. Long-term treatment for spontaneous coronary artery dissection pursues several main goals including antianginal therapy, prevention of recurrence, assessment, and management of extra coronary vascular abnormalities, and improvement of quality of life. To improve the quality of life in patients with SCAD, consider cardiac rehabilitation referral and manage patients comorbidities.
Algorithm for management of acute spontaneous coronary artery dissection: A Scientific Statement From the American Heart Association
Algorithm for management of acute spontaneous coronary artery dissection.[1]
Management of Acute Spontaneous Coronary Artery Dissection | |||||||||||||||||||||||||||||||||||||||
| Clinically stable without high-risk anatomy | Clinically stable with high-risk anatomy (i.e., left main or proximal 2-vessel dissection) | Active/ongoing ischemia or hemodynamic instability | |||||||||||||||||||||||||||||||||||||
❑ Conservative therapy ❑ Monitor as inpatient 3–5 days | ❑ Consider CABG ❑ Conservative Rx may be reasonable | ||||||||||||||||||||||||||||||||||||||
Abbreviations: CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; Rx, management.
Acute Management
- Acute management of myocardial infarction in SCAD is medical therapy in approximately 80% of the patients. Myocardial infarction in the context of SCAD is different from the myocardial infarction in the context of atherosclerosis and therefore makes it unfavorable for revascularization approaches.[2]
- Percutaneous coronary intervention (PCI) can be considered in high risk patients, such as:
- Patients with following clinical presentations:
- Persistent chest pain with evidence of worsening ischemia
- Hemodynamic instability
- Shock
- Ventricular arrhythmias
- Patients with following vascular involvement:
- Multi-vessel proximal dissections
- Left main artery dissection
- Ostial left anterior descending artery dissection
- Patients with following clinical presentations:
- Management with PCI may be associated with several adverse events, including:
Long-Term Treatment Approach
- Long-term treatment for spontaneous coronary artery dissection pursues several main goals:[2]
- Antianginal therapy
- Prevention of recurrence
- Assessment and management of extra coronary vascular abnormalities
- Improvement of quality of life
Management of Chest Pain
- To manage of chest pain in patients with SCAD consider the followings:[2]
- Antianginal medications
- Consider further testing to rule out underlying ischemia
- Consider other possible diagnoses
Prevention
- To reduce the risk of SCAD recurrence, the following should be considered:[2]
- Beta-blocker therapy
- Management of hypertension
- Maintaining physical activity
Assessment of Vascular Abnormalities
- To identify patients with SCAD-associated conditions, imaging with CT angiography or magnetic resonance angiography is recommended.[2]
Improvement in Quality of life
- To improve the quality of life in patients with SCAD, consider:[2]
- Cardiac rehabilitation referral
- Manage patients comorbidities
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 2.2 2.3 2.4 2.5 Kim, Esther S.H.; Longo, Dan L. (2020). "Spontaneous Coronary-Artery Dissection". New England Journal of Medicine. 383 (24): 2358–2370. doi:10.1056/NEJMra2001524. ISSN 0028-4793.