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Acute coronary syndromes
Spontaneous coronary artery dissection
  1. Christian J M Vrints
  1. Correspondence to Professor Dr Christian JM Vrints, Antwerp University Hospital, Department of Cardiology, Wilrijkstraat 10, 2650 Edegem, Belgium; chris.vrints{at}uza.be

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Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome or sudden cardiac death. Initial reports on this condition were scarce as they were based on postmortem examination of fatal cases. Currently, the clinical recognition of SCAD has increased as coronary angiography is utilised frequently in the clinical evaluation of patients with acute coronary syndromes. Moreover, intracoronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), which provide detailed morphological information on coronary lesions and on the location of dissection planes between the different layers of the arterial wall, have enabled a more detailed clinical assessment of SCAD. Furthermore, non-invasive coronary angiography by multidetector computed tomography (MDCT) has been used for longitudinal follow-up evaluation of patients with SCAD.

The clinical presentation of SCAD depends on the extent and the flow limiting severity of the coronary dissection, and ranges from asymptomatic to unstable angina, acute myocardial infarction, and ventricular arrhythmias to sudden cardiac death. As several diseases and conditions have been associated with SCAD it therefore probably constitutes a heterogeneous entity.

The use of coronary stents represented a breakthrough in the management of iatrogenic coronary dissections occurring during percutaneous interventions. However, in SCAD their application should be balanced against the expected outcome after a spontaneous natural course of this condition, because coronary stenting may end up in a ‘full metallic jacket’ covering of a long segment of the coronary artery. Current insights into the aetiology, pathogenesis, diagnostic imaging and therapeutic management of SCAD are reviewed.

Definition

Coronary artery dissection can be primary or secondary. Primary dissections occur spontaneously whereas secondary dissections occur as an extension from aortic root dissection or following an insult as a consequence of coronary angiography, coronary intervention, cardiac surgery or chest trauma.

Dissection of the coronary artery results in separation of the …

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