Author + information
- Received February 14, 2018
- Accepted March 6, 2018
- Published online June 4, 2018.
- Giorgio Quadri, MDa,∗ (, )
- Enrico Cerrato, MDa,
- Javier Escaned, MD, PhDb,
- Cristina Rolfo, MDa,
- Francesco Tomassini, MDa,
- Fabio Ferrari, MDa,
- Fabio Mariani, MDa and
- Ferdinando Varbella, MDa
- aUnità Funzionale Interaziendale di Emodinamica, Ospedale degli Infermi di Rivoli e AOU San Luigi Gonzaga di Orbassano, Turin, Italy
- bInterventional Cardiology, Hospital Clinico San Carlos, Madrid, Spain
- ↵∗Address for correspondence:
Dr. Giorgio Quadri, Unità Funzionale Interaziendale di Emodinamica, S.C. Cardiologia, Ospedale degli Infermi, Via Rivalta 29, 10098 Rivoli, Turin, Italy.
Spontaneous coronary artery dissection (SCAD) accounts for up to 25% of acute coronary syndromes in women <60 years of age (1). In the absence of trial-based evidence, the decision to opt for medical or interventional management of SCAD is based on patient outcomes in observational registries (2,3). In general, medical treatment is advised in “stable” SCAD patients, restricting percutaneous coronary intervention to patients with high-risk features such as left main dissection, ongoing or recurrent ischemia, ventricular arrhythmias, or cardiogenic shock (4). However, little emphasis is made on the dynamic nature of the SCAD and the potential for patient worsening after the initial treatment decision.
Four 40-year-old women (Patients A, B, C, and D [Figures 1A, 1B, 1C, and 1D, respectively]) presenting to our hospital with acute coronary syndromes presented angiographic features of SCAD (Figures 1, A1, B1, C1, and D1, Online Videos 1, 3, 5, and 7). Because of the absence of symptoms and/or high-risk features at the time of catheterization, they all were treated medically. However, 2 patients required urgent repeated coronary angiography due to the occurrence of cardiogenic shock (Patient A) and of angina at rest (Patient C), with evidence of severe progression of SCAD up to the left main coronary artery (Figures 1 and A2, Online Video 2) and proximal circumflex (Figures 1 and C2, Online Video 6), respectively, with the need of subsequent extensive percutaneous transluminal coronary angioplasty with multiple drug-eluting stents/bioresorbable scaffold implantation. By contrast, Patients B and D underwent elective in-hospital angiographic control, which showed complete SCAD healing (Figures 1, B2, and D2, Online Videos 4 and 8).
Due to the paucity of prospective data, management of SCAD constitutes an unmet need in clinical practice. These cases serve as a reminder of the unpredictability of SCAD evolution after an initial management decision, and of the importance of a close surveillance of patients with this condition.
Dr. Varbella has received institutional research grants from Medtronic, Abbott, Boston Scientific, Kardia, Alvi Medica CID, Menarini, and Servier; lecture fees from Stentys, AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Bayer, and Pfizer; and travel expenses from Orbus Neich, Biosensors, Sanitex, and Meril. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 14, 2018.
- Accepted March 6, 2018.
- 2018 American College of Cardiology Foundation
- Tweet M.S.,
- Eleid M.F.,
- Best P.J.M.,
- et al.
- Saw J.,
- Mancini G.B.J.,
- Humphries K.H.