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• "Definite Diagnosis of Spontaneous Coronary Artery Dissection: An Unsettled Issue"
  Adriano Caixeta
  Published on: 29 November 2016

• Published on: 29 November 2016

  "Definite Diagnosis of Spontaneous Coronary Artery Dissection: An Unsettled Issue"

  • Adriano Caixeta, Interventional Cardiologist
  • Other Contributors:
    • Jamil R. Cade

  We read with great interest the manuscript by Faden et al. (1) entitled "A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium" when it was published online July 13. Using the Healthcare Cost and Utilization Project national database, the authors evaluated over 4 million pregnancy-related discharges, looking at the prevalence and outcomes of pregnancy-associated spontaneous cor...

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  We read with great interest the manuscript by Faden et al. (1) entitled "A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium" when it was published online July 13. Using the Healthcare Cost and Utilization Project national database, the authors evaluated over 4 million pregnancy-related discharges, looking at the prevalence and outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD). By applying the International Classification of Diseases, 9th Revision (ICD-9) 79 cases of P-SCAD were identified, resulting in a prevalence of 1.81 per 100,000 pregnancies. Although this study stands out as the largest cohort thus far assessing P-SCAD, a few shortcomings should be highlighted. First, the methodology for P-SCAD search and identification included the ICD-9 medical code 412.12 represents a general definition of coronary artery dissection; there is no specific classification for SCAD in either the ICD -9 or in the recent ICD-10-CM (diagnosis code I25.42). Therefore, the 79 cases identified by the investigators may have included coronary artery dissections arising from other causes including atherosclerosis. The genuine classification of SCAD should be non-atherosclerotic. In addition, other ambiguous findings by angiography, such as thrombus, may also mimic SCAD (2). Prior study evaluating pregnant and postpartum women with myocardial infarction showed that its pathophysiology includes SCAD in 43% of cases, atherosclerosis in 27%, intracoronary thrombus in 17%, and normal coronary arteries in 11% (3). Second, despite its well-known limitations, invasive coronary angiography is still the main tool for recognizing this condition; other intravascular imaging such as intravascular ultrasound and optical coherence tomography have been recently used to enhanced its diagnostic accuracy. Of note, the pathognomonic appearance of SCAD on angiography--contrast dye staining of arterial wall with multiple radiolucent lumen--is less prevalent among all the findings, making the diagnostic ability of invasive angiography limited and challenging (5). In the present study by Faden et al. there is no mention about the angiographic findings of those patients, making the definite and final diagnosis of P-SCAD debatable. Had the authors reassessed all coronary invasive angiography, the ability to definitively diagnosis SCDA would have been improved; indeed, 10% of cases did not undergo invasive angiography, so the final diagnosis P-SCDA could only be extracted from the data set alone. Finally, when assessing the risk factors for P-SCAD, the authors demonstrated that chronic hypertension and lipid profile abnormalities were highly prevalent in relation to SCAD, which is in disagreement with prior studies showing that most patients had no risk factors for coronary artery disease (4). Likewise, a high rate of prior coronary angioplasty and, specifically, coronary artery bypass graft surgery (34%) in this cohort may suggest the inclusion of patients with coronary atherosclerosis.

  References:

  1. Faden MS, Bottega N, Benjamin A, Brown RN. A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium. Heart 2016;0:1-6. doi:10.1136/heartjnl-2016-309403.

  2. Cade JR, Abizaid A, Caixeta A. Organized Thrombus Mimicking Spontaneous Coronary Artery Dissection. JACC Cardiovasc Interv. 2014; 7(12):1458.

  3. Elkayam U, Jalnapurkar S, Barakkat MN, Khatri N, Kealey AJ, Mehra A, et al. Pregnancy-associated acute myocardial infarction: a review of contemporary experience in 150 cases between 2006 and 2011. Circulation. 2014;129(16):1695-702.

  4. Cade JR, Szarf G, de Siqueira ME, Chaves A, Andrea JC, Figueira HR, et al. Pregnancy-associated spontaneous coronary artery dissection: insights from a case series of 13 patients. Eur Heart J Cardiovasc Imaging. 2016 [Epud ahead of print].

  5. Saw J. Coronary angiogram classification of spontaneous coronary artery dissection. Catheter Cardiovasc Interv. 2014;84(7):1115-22.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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