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Abstract
Introduction Spontaneous coronary artery dissection (SCAD) is a rare and under-diagnosed cause of acute coronary syndrome (ACS), representing 2–4% of cases. There are no randomised control trials on the subject, therefore management is based on observational studies, case reports and extrapolation of advice from established ACS guidelines.
Methods A search of the McKesson cardiology software identified 13 patients with a SCAD diagnosis on angiogram reports from September 2015 to February 2022. The diagnosis was made on visual inspection of the images by the operator at the time of angiogram (figure 1). Patient data was collected from both electronic records and patient charts. Microsoft Excel was used to generate descriptive statistics of the data.
Results Patient characteristics are demonstrated in table 1. The majority of patients were male (61.5%), 92.3% had a family history of ACS and 61.5% had a current or past smoking history. Laboratory values, culprit vessel and management are shown in table 2. The left anterior descending artery was most commonly affected. There was no incidence of multi-vessel SCAD. All patients were treated with aspirin and 92.3% had dual anti-platelet therapy (DAPT), which included one patient also taking an anticoagulant. Ticagrelor was used twice as often as clopidogrel. Two patients (15.4%) had percutaneous coronary intervention (PCI) with drug-eluting stents for ongoing chest pain with dynamic ECG changes. Mean duration of in-hospital stay was 5.8 days. Over half of patients (53.8%) had a re-look angiogram. This was carried out a median of 57 days after the original procedure. There was no incidence of recurrent SCAD in the study period (figure 2).
Patient Characteristics (N=13)
Presentation and management
A 33 year old female patient with SCAD of the first diagonal
Re-look angiogram 2 months following SCAD diagnosis showing a patent vessel
Conclusions SCAD is infrequently encountered in a single Irish centre. In line with current international practice, PCI is generally avoided, and patients managed with DAPT, beta-blockers, ace-inhibitors and statins. However, there is notable heterogeneity of patient characteristics, risk factor profiles and follow-up. Although patient numbers in this study are small, over half are male. This is in contrast to other studies reporting that females account for approximately 90% of cases. Perhaps cases of SCAD in male patients with more traditional risk factors for ischaemic heart disease are being under-diagnosed, with the cause of ACS being attributed to atherosclerotic plaque rupture. Certainly there is a need for guidelines based on randomised control trials for the management of SCAD, particularly in relation to the use of anti-coagulation and the optimal duration of DAPT.