Spontaneous coronary artery dissection diagnostic approach

Jump to navigation Jump to search

Spontaneous Coronary Artery Dissection Microchapters

Home

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Spontaneous coronary artery dissection from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Angiography

CT

MRI

Echocardiography

Other Imaging Findings

Other Diagnostic Studies

Treatment

Treatment Approach

Medical Therapy

Percutaneous Coronary Intervention

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Type 1

Type 2A

Type 2B

Type 3

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Synonyms and keywords: SCAD

Overview

Coronary angiography is the standard for diagnosing spontaneous coronary artery dissection. Adjunctive imaging modalities such as intravascular ultrasonography (IVUS), optical coherence tomography (OCT), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) may offer complementary details for establishing a definitive diagnosis.

Algorithm for Diagnosis of Spontaneous Coronary Artery Dissection in the Setting of Acute Coronary Syndrome: A Scientific Statement From the American Heart Association


Algorithm for diagnosis of spontaneous coronary artery dissection (SCAD) in the setting of acute coronary syndrome.[1]

 
 
 
 
 
 
 
 
Coronary angiography after intracoronary nitrates
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Type 1 SCAD
(arterial wall stain, multiple lumens)
 
 
 
Type 2 SCAD
(intramural hematoma, diffuse, smooth stenoses)
 
 
 
Type 3 SCAD
(mimics atherosclerosis)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If diagnostic uncertainty, consider adjunctive diagnostic strategies:
❑  OCT/IVUS if feasible/safe
❑  CT coronary angiography
❑  CTA/MRA/angiographic imaging for extracoronary vasculopathy/FMD
❑  Repeat coronary angiography at 6–8 weeks
 
 
 
 
 
 
 
 


Abbreviations: CT, computed tomography; CTA, computed tomography angiography; FMD, fibromuscular dysplasia; IVUS, intravascular ultrasonography; MRA, magnetic resonance angiography; OCT, optical coherence tomography.

Algorithm for Angiographic Diagnosis of Non-Atherosclerotic Spontaneous Coronary Artery Dissection


Algorithm for the Angiographic Diagnosis and Confirmation of Spontaneous Coronary Artery Dissection[2]

 
 
 
 

Presence of features that raise suspicion for SCAD?
(click for details)


❑  Myocardial infarction in young women (age ≤50)

❑  Absence of traditional cardiovascular risk factors

❑  Little or no evidence of coronary atherosclerosis

❑  Peripartum state

❑  History of fibromuscular dysplasia

❑  History of connective tissue disorder or systemic inflammation

    ❑  Marfan's syndrome

    ❑  Type 4 Ehlers-Danlos syndrome

    ❑  Loeys-Dietz syndrome

    ❑  Cystic medial necrosis

    ❑  Systemic lupus erythematosus

    ❑  Crohn's disease

    ❑  Ulcerative colitis

    ❑  Polyarteritis nodosa

    ❑  Sarcoidosis

    ❑  Churg-Strauss syndrome

    ❑  Wegener's granulomatosis

    ❑  Rheumatoid arthritis

    ❑  Giant cell arteritis


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Perform early coronary angiography

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Presence of type 1 SCAD lesion characteristics?
(click for details)


❑  Contrast staining of arterial wall

❑  Multiple radiolucent lumens

❑  Contrast hang-up or slow clearing from the lumen


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Type 1 SCAD most likely
 
 
 
 
 

Presence of type 2 SCAD lesion characteristics?
(click for details)


❑  Diffuse lesion (typically >20–30 mm)

❑   Smooth luminal narrowing with varying severity

❑  Involvement of mid to distal segments


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stenosis relieved by intracoronary nitroglycerin?
 
 
 
 
 

Look for type 3 SCAD lesion characteristics
(click for details)


❑  Focal or tubular stenosis (typically <20 mm)

❑  Mimics atherosclerosis

❑  Additional features

    ❑  No atherosclerosis in other arteries

    ❑  Long lesions (11–20 mm)

    ❑  Hazy stenosis

    ❑  Linear stenosis


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 

Type 3 SCAD most likely

❑  Consider OCT or IVUS for definitive diagnosis

❑  Reassess with angiography in 4 to 6 weeks

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Type 2 SCAD most likely

❑  Consider OCT or IVUS for definitive diagnosis

❑  Reassess with angiography in 4 to 6 weeks

 
 
 
 

References

  1. Hayes, Sharonne N.; Kim, Esther S.H.; Saw, Jacqueline; Adlam, David; Arslanian-Engoren, Cynthia; Economy, Katherine E.; Ganesh, Santhi K.; Gulati, Rajiv; Lindsay, Mark E.; Mieres, Jennifer H.; Naderi, Sahar; Shah, Svati; Thaler, David E.; Tweet, Marysia S.; Wood, Malissa J. (2018). "Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association". Circulation: CIR.0000000000000564. doi:10.1161/CIR.0000000000000564. ISSN 0009-7322.
  2. 2.0 2.1 Saw J (2014). "Coronary angiogram classification of spontaneous coronary artery dissection". Catheter Cardiovasc Interv. 84 (7): 1115–22. doi:10.1002/ccd.25293. PMID 24227590.