First AHA Statement on Spontaneous Coronary Artery Dissection

Megan Brooks

March 20, 2018

For the first time, the American Heart Association (AHA) has issued a scientific statement on spontaneous coronary artery dissection (SCAD), which they hope will "spur a change in the paradigm of care for women and men with SCAD."  

Despite advances in the understanding of this condition, dissemination of new knowledge has been slow, and SCAD continues to be misdiagnosed, underdiagnosed, and managed as atherosclerotic acute coronary syndrome (ACS), which may harm patients with SCAD, the statement says.

"The statement was important since the learnings about SCAD occurring over the past 8 to 10 years are markedly different from what most cardiologists were taught in training," Sharonne N Hayes, MD, Mayo Clinic, Rochester, Minnesota, chair of the statement writing group, told theheart.org | Medscape Cardiology.

"We felt that enough new science had been published and that many of these research findings warrant rethinking how we've diagnosed and treated SCAD in the past," Hayes said.

The statement was published online February 22 in Circulation.

Proper diagnosis is critical. First, one needs to suspect it. Dr Sharonne N Hayes

 

One key "take-home" message from the statement, said Hayes, is that a SCAD event is a "completely different entity compared to one due to atherosclerosis. It mainly happens to premenopausal women, with different risk factors such as pregnancy and fibromuscular dysplasia."

The statement provides detailed guidance about how to properly diagnose SCAD. "Proper diagnosis is critical," said Hayes. "First, one needs to suspect it. We've been misdiagnosing it, largely missing intramural hematomas, which is one way SCAD presents, so we now know it's not nearly as rare as previously believed."

Once SCAD is identified, the treatment is also different than for a myocardial infarction (MI) due to atherosclerosis, said Hayes. Conservative therapy is generally the preferred strategy in patients with SCAD who are clinically stable and without objective evidence of ongoing ischemia, and it has generally been associated with favorable outcomes, the statement notes.

A conservative strategy is additionally appropriate in patients with occluded distal vessels or distal branches that would not routinely be amenable to percutaneous coronary intervention.

"Stenting is more challenging in these patients [with] more complications and lower success rates. And SCAD arteries tend to heal on their own if left alone. The statement provides diagnostic and treatment algorithms to help clinicians make SCAD-specific management decisions," Hayes said.

The statement also advises that all patients with MI caused by SCAD be referred for cardiac rehabilitation consistent with the secondary prevention, risk reduction, and psychosocial support strategy recommendations.

"The burden of recurrent SCAD and chest pain, depression, and anxiety are substantial and need to be addressed," Hayes commented.

While several key questions have yet to be answered, Hayes said she hopes that this first-ever statement on SCAD "increases awareness of SCAD among physicians and other health care providers and thus improves recognition and management of SCAD. This awareness must then initiate collaborative multicenter and prospective research efforts to help understand the natural history of SCAD and develop treatments to prevent SCAD complications and recurrence."

"We hope that it won't be too long before we have sufficient evidence to update it further," said Hayes.

Hayes has no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

Circulation. Published online February 22, 2018. Abstract

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