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Spontaneous coronary artery dissection differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Arzu Kalayci, M.D. [3]

Synonyms and keywords: SCAD

Overview

Spontaneous coronary artery dissection should be differentiated from other causes of acute coronary syndrome. Features suggestive of spontaneous coronary artery dissection include 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, and history of connective tissue disorder or systemic inflammatory disorder.

Differential Diagnosis

Albeit an infrequent condition, spontaneous coronary artery dissection (SCAD) should be included in the differential diagnosis of acute coronary syndrome, particularly among young women with risk factors such as vasculopathy, pregnancy, connective tissue disorder, systemic inflammation, strenuous exercise, emotional stress, or recreational drug use. While demographic and angiographic characteristics may be useful in differentiating SCAD from other causes of myocardial ischemia, intracoronary imaging such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) may be required for establishing a definitive diagnosis.


Differentiating spontaneous coronary artery dissection from other diseases

[1][2][3][4][5][6][7][8][9][10][11]







Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Symptom 1 Symptom 2 Symptom 3 Physical exam 1 Physical exam 2 Physical exam 3 Lab 1 Lab 2 Lab 3 Imaging 1 Imaging 2 Imaging 3
STEMI Chest discomfort with radiation to arms, neck, back, jaw Shortness of breath, dizziness, faint Nausea, vomiting, sweating Tachycardia, bradycardia Hypertension, hypotension, syncope S4 heart sound, rale, holosystolic murmur in apex ↑Troponin I, T ↑Creatin kinase MB (CKMB) ↑C-reactive protein, BNP Cardiac magnetic resonance imaging (CMR): myocardial edema, microvascular obstruction, intramyocardial hemorrhage, MI size Intravascular imaging during PCI Occlusive coronary thrombus formation superimposed on a ruptured or eroded atherosclerotic plaque Coronary angiography
Spontaneous coronary artery dissection Chest discomfort with radiation to arms, neck, back, jaw Shortness of breath, dizziness, faintness Nausea, vomiting, sweating Tachycardia, bradycardia Hypertension, hypotension, syncope rale, holosystolic murmur in apex ↑Troponin I, T ↑Creatin kinase MB (CKMB) Coronary angiography intravascular ultrasound (IVUS), optical coherence tomography (OCT) Coronary CT angiography Intimal tear, medial dissection, hemorrhage formation, false lumen formation.Hematoma formation in media, separation of two arterial layers, formation of false lumen, dissection of the true lumen Intracoronary imaging such as intravascular ultrasound (IVUS), optical coherence tomography (OCT) Mimicing ECG changes of STMI
Coronary vasospasm Chest discomfort with radiation to arms, neck, back, jaw Shortness of breath, dizziness, faintness Nausea, vomiting, sweating Tachycardia, bradycardia Hypertension, hypotension, syncope Rale, holosystolic murmur in apex ↑Troponin I, T ↑Creatin kinase MB (CKMB) IVUS findings: negative remodeling, diffuse intima, thick media, and wrinkles in the internal elastic membrane even in the absence of a significant coronary stenosis Morphologic changes in the artery at the site of the spasm, endothelium damaged, Platelets aggregation at this site releasing vasoactive substances, thrombin formation Coronary angiography and spasm provocation test occurring most often from midnight to early morning, Mimicing ECG changes of STMI

References

  1. ↑ Paulo, Manuel; Sandoval, Jorge; Lennie, Vera; Dutary, Jaime; Medina, Miguel; Gonzalo, Nieves; Jimenez-Quevedo, Pilar; Escaned, Javier; Bañuelos, Camino; Hernandez, Rosana; Macaya, Carlos; Alfonso, Fernando (2013). “Combined Use of OCT and IVUS in Spontaneous Coronary Artery Dissection”. JACC: Cardiovascular Imaging. 6 (7): 830–832. doi:10.1016/j.jcmg.2013.02.010. ISSN 1936-878X.
  2. ↑ Adlam, David; Alfonso, Fernando; Maas, Angela; Vrints, Christiaan; al-Hussaini, Abtehale; Bueno, Hector; Capranzano, Piera; Gevaert, Sofie; Hoole, Stephen P; Johnson, Tom; Lettieri, Corrado; Maeder, Micha T; Motreff, Pascal; Ong, Peter; Persu, Alexandre; Rickli, Hans; Schiele, Francois; Sheppard, Mary N; Swahn, Eva (2018). “European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection”. European Heart Journal. 39 (36): 3353–3368. doi:10.1093/eurheartj/ehy080. ISSN 0195-668X.
  3. ↑ . doi:10.1136/2Fhrt.53.4.363. Missing or empty |title= (help)
  4. ↑ Davies, Michael J. (1996). “The contribution of thrombosis to the clinical expression of coronary atherosclerosis”. Thrombosis Research. 82 (1): 1–32. doi:10.1016/0049-3848(96)00035-7. ISSN 0049-3848.
  5. ↑ YASUE, Hirofumi; MIZUNO, Yuji; HARADA, Eisaku (2019). “Coronary artery spasm — Clinical features, pathogenesis and treatment —”. Proceedings of the Japan Academy, Series B. 95 (2): 53–66. doi:10.2183/pjab.95.005. ISSN 0386-2208.
  6. ↑ Shepherd, John T.; Vanhoutte, Paul M. (1985). “Spasm of the Coronary Arteries: Causes and Consequences (the Scientist’s Viewpoint)”. Mayo Clinic Proceedings. 60 (1): 33–46. doi:10.1016/S0025-6196(12)65280-X. ISSN 0025-6196.
  7. ↑ Koyama, Jun; Yamagishi, Masakazu; Tamai, Jun; Kawano, Shigeo; Daikoku, Satoshi; Miyatake, Kunio (1995). “Comparison of vessel wall morphologic appearance a sites of focal and diffuse coronary vasospasm by intravascular ultrasound”. American Heart Journal. 130 (3): 440–445. doi:10.1016/0002-8703(95)90349-6. ISSN 0002-8703.
  8. ↑ Miyao, Yuji; Kugiyama, Kiyotaka; Kawano, Hiroaki; Motoyama, Takeshi; Ogawa, Hisao; Yoshimura, Michihiro; Sakamoto, Tomohiro; Yasue, Hirofumi (2000). “Diffuse intimal thickening of coronary arteries in patients with coronary spastic angina”. Journal of the American College of Cardiology. 36 (2): 432–437. doi:10.1016/S0735-1097(00)00729-4. ISSN 0735-1097.
  9. ↑ Tweet, Marysia S.; Gulati, Rajiv; Williamson, Eric E.; Vrtiska, Terri J.; Hayes, Sharonne N. (2016). “Multimodality Imaging for Spontaneous Coronary Artery Dissection in Women”. JACC: Cardiovascular Imaging. 9 (4): 436–450. doi:10.1016/j.jcmg.2016.01.009. ISSN 1936-878X.
  10. ↑ Bulluck, Heerajnarain; Dharmakumar, Rohan; Arai, Andrew E.; Berry, Colin; Hausenloy, Derek J. (2018). “Cardiovascular Magnetic Resonance in Acute ST-Segment–Elevation Myocardial Infarction”. Circulation. 137 (18): 1949–1964. doi:10.1161/CIRCULATIONAHA.117.030693. ISSN 0009-7322.
  11. ↑ . doi:10.1016/j.carreu.2020.09.032. Missing or empty |title= (help)

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