title: Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes.
abstract: BACKGROUND
  Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is underdiagnosed and an important cause of myocardial infarction in young women. The frequency of predisposing and precipitating conditions and cardiovascular outcomes remains poorly described.
  
  
  RESULTS
  Patients with NA-SCAD prospectively evaluated (retrospectively or prospectively identified) at Vancouver General Hospital were included. Angiographic SCAD diagnosis was confirmed by 2 experienced interventional cardiologists and categorized as type 1 (multiple lumen), 2 (diffuse stenosis), or 3 (mimic atherosclerosis). Fibromuscular dysplasia screening of renal, iliac, and cerebrovascular arteries were performed with angiography or computed tomographic angiography/MR angiography. Baseline, predisposing and precipitating conditions, angiographic, revascularization, in-hospital, and long-term events were recorded. We prospectively evaluated 168 patients with NA-SCAD. Average age was 52.1±9.2 years, 92.3% were women (62.3% postmenopausal). All presented with myocardial infarction. ECG showed ST-segment elevation in 26.1%, and 3.6% had ventricular tachycardia/ventricular fibrillation arrest. Fibromuscular dysplasia was diagnosed in 72.0%. Precipitating emotional or physical stress was reported in 56.5%. Majority had type 2 angiographic SCAD (67.0%), only 29.1% had type 1, and 3.9% had type 3. The majority (134/168) were initially treated conservatively. Overall, 6 of 168 patients had coronary artery bypass surgery and 33 of 168 had percutaneous coronary intervention in-hospital. Of those treated conservatively (n=134), 3 required revascularization for SCAD extension, and all 79 who had repeat angiogram ≥26 days later had spontaneous healing. Two-year major adverse cardiac events were 16.9% (retrospectively identified group) and 10.4% (prospectively identified group). Recurrent SCAD occurred in 13.1%.
  
  
  CONCLUSIONS
  Majority of patients with NA-SCAD had fibromuscular dysplasia and type 2 angiographic SCAD. Conservative therapy was associated with spontaneous healing. NA-SCAD survivors are at risk for recurrent cardiovascular events, including recurrent SCAD.
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.). jsaw@mail.ubc.ca.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Saw
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Eve
authors.initials: E
authors.lastname: Aymong
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Tara
authors.initials: T
authors.lastname: Sedlak
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Buller
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Andrew
authors.initials: A
authors.lastname: Starovoytov
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Donald
authors.initials: D
authors.lastname: Ricci
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Simon
authors.initials: S
authors.lastname: Robinson
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Tycho
authors.initials: T
authors.lastname: Vuurmans
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Min
authors.initials: M
authors.lastname: Gao
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: Karin
authors.initials: K
authors.lastname: Humphries
authors.affiliation: From the Division of Cardiology, Vancouver General Hospital, Vancouver, BC (J.S., T.S., A.S., D.R., G.B.J.M.); Division of Cardiology, St Paul's Hospital, Vancouver, BC (E.A.); Division of Cardiology, St Michael's Hospital, Toronto, Ontario (C.E.B.); Division of Cardiology, Royal Jubilee Hospital, Victoria, BC (S.R.); Division of Cardiology, Royal Columbian Hospital, New Westminster, BC (T.V.); and BC Centre for Improved Cardiovascular Health, UBC, Vancouver, BC (M.G., K.H.).
authors.forename: G B John
authors.initials: GB
authors.lastname: Mancini
mesh_terms: D000328:Adult; D002170:Canada; D015984:Causality; D017023:Coronary Angiography; D003330:Coronary Vessel Anomalies / Q000453:epidemiology* / Q000209:etiology; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D005260:Female; D005352:Fibromuscular Dysplasia / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D017063:Outcome Assessment, Health Care; D062645:Percutaneous Coronary Intervention; D011446:Prospective Studies; D012307:Risk Factors; D013315:Stress, Psychological / Q000453:epidemiology*; D014652:Vascular Diseases / Q000151:congenital* / Q000453:epidemiology / Q000209:etiology; D055815:Young Adult
keywords: coronary angiography; coronary artery dissection, spontaneous; fibromuscular dysplasia; myocardial infarction; women