title: Spontaneous coronary artery dissection: new insights into diagnosis and treatment.
abstract: Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.
authors.affiliation: aDepartment of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain bDivision of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA cDivision of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada.
authors.forename: Fernando
authors.initials: F
authors.lastname: Alfonso
authors.forename: Teresa
authors.initials: T
authors.lastname: Bastante
authors.forename: Marcos
authors.initials: M
authors.lastname: García-Guimaraes
authors.forename: Eduardo
authors.initials: E
authors.lastname: Pozo
authors.forename: Javier
authors.initials: J
authors.lastname: Cuesta
authors.forename: Fernando
authors.initials: F
authors.lastname: Rivero
authors.forename: Amparo
authors.initials: A
authors.lastname: Benedicto
authors.forename: Paula
authors.initials: P
authors.lastname: Antuña
authors.forename: Teresa
authors.initials: T
authors.lastname: Alvarado
authors.forename: Rajiv
authors.initials: R
authors.lastname: Gulati
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Saw
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D000328:Adult; D000367:Age Factors; D000368:Aged; D002317:Cardiovascular Agents / Q000627:therapeutic use; D000072700:Conservative Treatment / Q000009:adverse effects; D017023:Coronary Angiography; D003330:Coronary Vessel Anomalies / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging / Q000379:methods; D015425:Myocardial Reperfusion / Q000009:adverse effects; D011237:Predictive Value of Tests; D012307:Risk Factors; D012737:Sex Factors; D041623:Tomography, Optical Coherence; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D014652:Vascular Diseases / Q000151:congenital* / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy; D057832:Watchful Waiting
chemical_list: D002317:Cardiovascular Agents