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Epidemiology and Pathophysiology of Spontaneous Coronary Artery Dissection
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This entry is adapted from the peer-reviewed paper 10.3390/jcm12010154

Spontaneous Coronary Artery Dissection (SCAD) refers to the spontaneous separation of the layers of the vessel wall caused by intramural hemorrhage, with or without an intimal tear. This condition is not associated with trauma, atherosclerosis or iatrogenic causes and may be an expression of an underlying systemic arterial disease, namely, fibromuscular dysplasia. 

spontaneous coronary artery dissection multimodality imaging coronary imaging

1. Epidemiology

1.1. Sex, Age, Ethnicity

The real incidence of spontaneous coronary artery dissection (SCAD) is difficult to define as it is often underestimated. Although SCAD is an uncommon cause of all heart attacks (<1% of all acute myocardial infarctions are caused by spontaneous dissections) [1], its incidence in acute myocardial infarctions in women remains considerable. It is estimated that about 1/3 of acute myocardial infarctions in women <50 years are caused by spontaneous dissections [2][3]. The “typical” SCAD patient is a middle-aged woman with few traditional cardiovascular risk factors, albeit acute coronary syndrome (ACS) due to SCAD has been observed from the late teens to the ninth decade of life [3]. SCAD is likely influenced by a combination of factors that include sex; hormonal fluctuations; underlying arteriopathies; genetics; and environmental, physical, and emotional precipitants. Women comprise 87% to 95% of SCAD with a mean age of presentation between 44 and 53 years [4][5][6]. Data on SCAD in men are limited because the prevalence of this condition among men is low. SCAD in men is more frequently associated with excessive physical exertion (e.g., exercise or heavy lifting) and tends to have a lower prevalence of fibromuscular dysplasia than in women with SCAD [1].
White Caucasian ethnicity predominates in most observational series; however, cases have been described in many racial groups [3]. SCAD fatalities are uncommon; however, their incidence remains unknown, due to challenges with accurate post-mortem diagnosis [7].

1.2. Pregnancy-Associated SCAD

The strong female sex predominance of SCAD and the association with pregnancy and perhaps multiparity strongly suggest some association between female sex hormones and the pathophysiology of SCAD. However, the precise relationship remains unknown, and SCAD has been described in men, post-menopausal and nulliparous women. SCAD has been described in patients taking hormonal contraception and hormone replacement therapy. However, it has never been demonstrated that exogenous hormone use is more prevalent in SCAD or that continuing to take hormones after SCAD increases the risk of recurrence [3]. Pregnancy-associated SCAD (P-SCAD; usually defined as SCAD occurring during gestation or within 12 months of delivery) accounts for approximately 5–10% of cases of SCAD. Reportedly accounts for 10–22% of ACS events in pregnancy and 23–67% of postpartum ACS [2][3][8]. There is growing evidence that P-SCAD is associated with a more severe phenotype with proximal and extensive dissections and larger infarcts. SCAD has also been observed in association with multi-parity and pre-eclampsia in some studies [9][10][11][12].

1.3. Inflammatory Conditions

Even if SCAD is not frequently related to systemic inflammatory disorders, laboratory testing to rule out autoimmune diseases may be taken into consideration in the post-acute setting of patients symptomatic of rheumatologic conditions [2].

1.4. Inheritance and Genetics

SCAD occurs rarely in patients with known hereditary conditions.
Familial SCAD is rare [13], and pathogenic variants were identified in only 3.5% of unselected patients in a genome sequencing study, suggesting that most cases are sporadic; therefore, at present, testing genetic is not recommended in all cases of SCAD [14].

1.5. Risk Factors for Ischemic Heart Disease

Although the prevalence of classic risk factors for ischemic disease is low, coronary dissection is more frequently associated with arterial hypertension and less frequently with diabetes mellitus [15][16][17]. Indeed, whilst risk factors are less common in SCAD patients than in atherosclerotic patients, SCAD should not be excluded from diagnostic consideration when risk factors are present.
The left anterior descending coronary artery is involved in about 40% of SCAD [18][19], mainly in its mid-to-distal segments. Other vessels or multivessel SCADs are less common [2][20].

2. Pathophysiology

SCAD is an acute coronary event linked to the formation and expansion of an intramural hematoma that determines the separation of the intima or intima-media complex from the underlying vessel lumen creating a false lumen that compresses the true light. This process determines, depending on the degree of compression of the true lumen, ischemia, or myocardial infarction. Two mechanisms have been hypothesized to explain the entry of blood into the vessel wall [21][22]:
Inside-out mechanism: Rupture of the endothelium with the passage of blood from the true lumen to the subintimal space.
Outside-in mechanism: Formation of “de novo” hematoma at the level of the middle tunic due to rupture of the vasa vasorum or by dissection of the medium tunic with a consequent false lumen. Several pieces of evidence, acquired with the IVUS (intravascular ultrasound)/ OCT (optical coherence tomography) method, support this hypothesis.
Frequently, there is no communication between the true and false lumen and when fenestrations are created, these derive from the breaking of the false lumen into the true lumen and not vice versa; in addition, serial angiography performed during SCAD have shown that the intramural hematoma precedes the intimal dissection [21][22][23][24]. More rarely, the occlusion of the true lumen may be due to thrombosis generated by the exposure of the pro-thrombogenic subendothelium following injury to the intima.
To explain the pathogenesis, predisposing conditions have been identified that cause the weakening of the vascular wall and precipitating conditions that, by increasing the wall stress, favor its rupture. There is a complex relationship between a vulnerable subject and potential triggers that initiate a spontaneous arterial tear or intramural hematoma
Among the predisposing conditions, the most frequent is fibromuscular dysplasia (FMD), a non-atherosclerotic segmental idiopathic disease of the medial tunic of the arterial walls manifested by stenosis, aneurysms, tortuosity, or spontaneous dissections of small and medium arteries caliber. FMD is linked to the proliferation of smooth muscle cells and fibrous tissue [25]. The association of SCAD with multifocal FMD in arteries has been the most frequently found and coronary dissection could be the first manifestation of FMD [20]. Multifocal FMD is defined from an angiographic point of view as areas of alternating stenosis and dilatation. There is a high prevalence of concomitant extra coronary arterial anomalies in registries of SCAD patients. In patients without diagnostic features of FMD, other arterial abnormalities have been reported, such as dissections, aneurysms, or arterial tortuosity (78%) [26][27][28].
About 80–90% of patients with FMD are female (prevalence about 4% of the population). The presence of any extracoronary vascular abnormalities (EVA) in patients with SCAD is high and includes aneurysms and noncoronary dissections. The cerebral aneurysm has been detected in 7 to 14% of patients with SCAD who have undergone screening [29][30][31].
Whether or not SCAD is a coronary manifestation of fibromuscular dysplasia or a unique but related entity with a considerable number of arterial features in common, SCAD may be a forme fruste of an underlying systemic arteriopathy that leaves the affected patient vulnerable to dissection when exposed to arterial shear stress related to an inciting trigger [1].

References

  1. Kim, E.S.H. Spontaneous Coronary-Artery Dissection. N. Enlg. J. Med. 2020, 383, 2358–2370.
  2. Hayes, S.N.; Kim, E.S.H.; Saw, J.; Adlam, D.; Arslanian-Engoren, C.; Economy, K.E.; Ganesh, S.K.; Gulati, R.; Lindsay, M.E.; Mieres, J.H.; et al. Spontaneous Coronary Artery Dissection: Current State of the Science A Scientific Statement From the American Heart Association. Circulation 2018, 137, e523–e557.
  3. Hayes, S.N.; Tweet, M.S.; Adlam, D.; Kim, E.S.H.; Gulati, R.; Price, J.E.; Rose, C.H. Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review. J. Am. Coll. Cardiol. 2020, 76, 961–984.
  4. Kok, S.N.; Hayes, S.N.; Cutrer, F.M.; Raphael, C.E.; Gulati, R.; Best, P.J.M.; Tweet, M.S. Prevalence and Clinical Factors of Migraine in Patients With Spontaneous Coronary Artery Dissection. J. Am. Heart Assoc. 2018, 7, e010140.
  5. Lettieri, C.; Zavalloni, D.; Rossini, R.; Morici, N.; Ettori, F.; Leonzi, O.; Latib, A.; Ferlini, M.; Trabattoni, D.; Colombo, P.; et al. Management and Long-Term Prognosis of Spontaneous Coronary Artery Dissection. Am. J. Cardiol. 2015, 116, 66–73.
  6. Saw, J.; Starovoytov, A.; Humphries, K.; Sheth, T.; So, D.; Minhas, K.; Brass, N.; Lavoie, A.; Bishop, H.; Lavi, S.; et al. Canadian spontaneous coronary artery dissection cohort study: In-hospital and 30-day outcomes. Eur. Heart J. 2019, 40, 1188–1197.
  7. Adlam, D.; Fernando, A.; Maas, A.; Persu, A.; Vrints, C. Part III — Spontaneous Coronary Artery Dissections. In The PCR-EAPCI Textbook, 2nd ed.; PCR editor, 2012; Available online: https://www.escardio.org/Education/Textbooks/interventional-cardiology (accessed on 1 October 2022).
  8. Adlam, D.; Alfonso, F.; Maas, A.; Vrints, C.; Al-Hussaini, A.; Bueno, H.; Capranzano, P.; Gevaert, S.; Hoole, S.P.; Johnson, T.; et al. European Society of Cardiology, acute cardiovascular care association, SCAD study group: A position paper on spontaneous coronary artery dissection. Eur. Heart J. 2018, 39, 3353–3368.
  9. Hassan, S.; Prakash, R.; Starovoytov, A.; Saw, J. Natural History of Spontaneous Coronary Artery Dissection With Spontaneous Angiographic Healing. JACC Cardiovasc. Interv. 2019, 12, 518–527.
  10. Tweet, M.S.; Hayes, S.N.; Codsi, E.; Gulati, R.; Rose, C.H.; Best, P.J. Spontaneous Coronary Artery Dissection Associated with Pregnancy. J. Am. Coll. Cardiol. 2017, 70, 426–435.
  11. Al-Hussaini, A.; Abdelaty, A.; Gulsin, G.S.; Arnold, J.R.; Garcia-Guimaraes, M.; Premawardhana, D.; Budgeon, C.; Wood, A.; Natarajan, N.; Mangion, K.; et al. Chronic infarct size after spontaneous coronary artery dissection: Implications for pathophysiology and clinical management. Eur. Heart J. 2020, 41, 2197–2205.
  12. Faden, M.S.; Bottega, N.; Benjamin, A.; Brown, R.N. A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium. Heart 2016, 102, 1974–1979.
  13. Goel, K.; Tweet, M.; Olson, T.M.; Maleszewski, J.J.; Gulati, R.; Hayes, S.N. Familial spontaneous coronary artery dissection: Evidence for genetic susceptibility. JAMA Intern. Med. 2015, 175, 821–826.
  14. Carss, K.J.; Baranowska, A.A.; Armisen, J.; Webb, T.R.; Hamby, S.E.; Premawardhana, D.; Al-Hussaini, A.; Wood, A.; Wang, Q.; Deevi, S.V.V.; et al. Spontaneous Coronary Artery Dissection: Insights on Rare Genetic Variation From Genome Sequencing. Circ. Genom. Precis. Med. 2020, 13, e003030.
  15. Saw, J.; Starovoytov, A.; Aymong, E.; Inohara, T.; Alfadhel, M.; McAlister, C.; Samuel, R.; Grewal, T.; Parolis, J.A.; Sheth, T.; et al. Canadian Spontaneous Coronary Artery Dissection Cohort Study: 3-Year Outcomes. J. Am. Coll. Cardiol. 2022, 80, 1585–1597.
  16. Adlam, D.; García-Guimaraes, M.; Maas, A.H.E.M. Spontaneous coronary artery dissection: No longer a rare disease. Eur. Heart J. 2019, 40, 1198–1201.
  17. Sharma, S.; Kaadan, M.I.; Duran, J.M.; Ponzini, F.; Mishra, S.; Tsiaras, S.V.; Scott, N.S.; Weinberg, I.; Ghoshhajra, B.; Lindsay, M.; et al. Risk Factors, Imaging Findings, and Sex Differences in Spontaneous Coronary Artery Dissection. Am. J. Cardiol. 2019, 123, 1783–1787.
  18. Russo, A.; Lettieri, C.; Caico, S.I.; Musumeci, G.; Rossini, R.; Castiglioni, B. Le dissezioni coronariche spontanee. G. Ital. Cardiol. 2018, 19, 488–494.
  19. Saw, J.; Aymong, E.; Mancini, G.J.; Sedlak, T.; Starovoytov, A.; Ricci, D. Nonatherosclerotic Coronary Artery Disease in Young Women. Can. J. Cardiol. 2014, 30, 814–819.
  20. Saw, J.; Aymong, E.; Sedlak, T.; Buller, C.E.; Starovoytov, A.; Ricci, D.; Robinson, S.; Vuurmans, T.; Gao, M.; Humphries, K.; et al. Spontaneous Coronary Artery Dissection. Circ. Cardiovasc. Interv. 2014, 7, 645–655.
  21. Waterbury, T.M.; Tweet, M.S.; Hayes, S.N.; Eleid, M.F.; Bell, M.R.; Lerman, A.; Singh, M.; Best, P.J.; Lewis, B.R.; Rihal, C.S.; et al. Early Natural History of Spontaneous Coronary Artery Dissection. Circ. Cardiovasc. Interv. 2018, 11, e006772.
  22. Waterbury, T.M.; Tarantini, G.; Vogel, B.; Mehran, R.; Gersh, B.J.; Gulati, R. Non-atherosclerotic causes ofacute coronary syndromes. Nat. Rev. Cardiol. 2020, 17, 229–241.
  23. Alfonso, F.; Paulo, M.; Lennie, V.; Dutary, J.; Bernardo, E.; Jiménez-Quevedo, P.; Gonzalo, N.; Escaned, J.; Bañuelos, C.; Pérez-Vizcayno, M.J.; et al. Spontaneous coronary artery dissection: Long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy. J. Am. Coll. Cardiol. Interv. 2012, 5, 1062–1070.
  24. Jackson, R.; Al-Hussaini, A.; Joseph, S.; van Soest, G.; Wood, A.; Macaya, F.; Gonzalo, N.; Cade, J.; Caixeta, A.; Hlinomaz, O.; et al. Spontaneous coronary artery dissection: Pathophysiological insights from optical coherence tomography. J. Am. Coll. Cardiol. Imaging 2019, 12, 2475–2488.
  25. Persu, A.; Touze, E.; Mousseaux, E.; Barral, X.; Joffre, F.; Plouin, P.-F. Diagnosis and management of fibromuscular dysplasia: An expert consensus. Eur. J. Clin. Investig. 2011, 42, 338–347.
  26. Toggweiler, S.; Puck, M.; Thalhammer, C.; Manka, R.; Wyss, M.; Bilecen, D.; Corti, R.; Amann-Vesti, B.R.; Lüscher, T.F.; Wyss, C.A. Associated vascular lesions in patients with spontaneous coronary artery dissection. Swiss Med. Wkly. 2012, 142, w13538.
  27. Kadian-Dodov, D.; Gornik, H.L.; Gu, X.; Froehlich, J.; Bacharach, J.M.; Chi, Y.-W.; Gray, B.H.; Jaff, M.R.; Kim, E.S.H.; Mace, P.; et al. Dissection and aneurysm in patients with fibromuscular dysplasia: Findings from the U.S. Registry for FMD. J. Am. Coll. Cardiol. 2016, 68, 176–185.
  28. Eleid, M.F.; Guddeti, R.R.; Tweet, M.S.; Lerman, A.; Singh, M.; Best, P.J.; Vrtiska, T.J.; Prasad, M.; Rihal, C.S.; Hayes, S.N.; et al. Coronary artery tortuosity in spontaneous coronary artery dissection: Angiographic characteristics and clinical implications. Circ. Cardiovasc. Interv. 2014, 7, 656–662.
  29. Yang, C.; Alfadhel, M.; Saw, J. Spontaneous Coronary Artery Dissection: Latest Developments and New Frontiers. Curr. Atheroscler. Rep. 2020, 22, 49.
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  31. Ricci, F.; Neumann, J.T.; Rübsamen, N.; Sörensen, N.A.; Ojeda, F.; Cataldo, I.; Zeller, T.; Schäfer, S.; Hartikainen, T.S.; Golato, M.; et al. High-sensitivity troponin I with or without ultra-sensitive copeptin for the instant rule-out of acute myocardial infarction. Front. Cardiovasc. Med. 2022, 9, 895421.
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Subjects: Cardiac & Cardiovascular Systems
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Gemma Marrazzo
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Stefano Palermi
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Fabio Pastore
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Massimo Ragni
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Mariarosaria De Luca
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Michele Gambardella
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Giancarlo Messalli
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Lucia Riegler
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Valeria Pergola
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Andrea Manto
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Antonello D’Andrea
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Update Date: 30 Dec 2022
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