Compartilhar
Informação da revista
Vol. 37. Núm. 11.Novembro 2018
Páginas 873-960
Compartilhar
Compartilhar
Baixar PDF
Mais opções do artigo
Visitas
91
Vol. 37. Núm. 11.Novembro 2018
Páginas 873-960
Letter to the Editor
DOI: 10.1016/j.repc.2018.08.005
Open Access
Focus on spontaneous coronary artery dissection: Where are we now?
Foco na disseção espontânea da artéria coronária: Onde estamos agora?
Visitas
91
Dario Buccheri
Interventional Cardiology, “S. Antonio Abate” Hospital, Via Cosenza, 80, 91016 Erice (TP), Italy
Conteúdo relacionado
Rev Port Cardiol 2018;37:707-1310.1016/j.repc.2017.07.019
Glória Abreu, Carlos Galvão Braga, João Costa, Pedro Azevedo, Jorge Marques
Rev Port Cardiol.2018;37:957-810.1016/j.repc.2018.10.006
Glória Abreu
Este item recebeu
91
Visitas

Under a Creative Commons license
Informação do artigo
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (1)
Dear Editor,
Texto Completo

I read with great interest the single-center experience on spontaneous coronary artery dissection (SCAD) recently published by Abreu and colleagues in this journal.1 The authors reported a case series consisting of 27 patients, admitted to the cardiology department between January 2010 and December 2016, with a diagnosis of acute coronary syndrome (ACS) due to ongoing SCAD.

The prevalence of SCAD was 0.5% among patients who underwent catheterization for suspected ACS (15 NSTEMI, 10 STEMI and two sudden cardiac arrest). Most were women (22 F:5 M) and the cohort's median age was 56±11 years.

Patient characteristics and clinical presentation with predisposing factors were reported in Table 1 of the article. They were managed mainly in a conservative manner (15 medical therapy vs. 12 PCI). It is not insignificant that four of the 15 patients managed conservatively had a myocardial infarction on follow-up and in two of these the initial treatment was modified, requiring a switch to coronary angioplasty, with no cases of stent thrombosis at follow-up. A close clinical follow-up with optical coherence tomography (OCT) for PCI-managed cases was recommended. Prognosis was good despite the high prevalence of reinfarction in-hospital or during follow-up.

Considering the high level of interest in this subject, the European Society of Cardiology, in partnership with the Acute Cardiovascular Care Association, has established a European SCAD registry as a platform for collaborative research with the aim of improving awareness of the condition for better management.

Here I would like to put forward some food for thought that could be useful and interesting for the Journal's readers.

Of note, Abreu et al. remarked that SCAD is still an underestimated entity due to the challenging diagnosis, in which a high degree of clinical suspicion plays a key role. In this regard, I would like to underline that emerging evidence shows that this underestimation is mainly due to the absence of the classic angiographic hallmarks, which are lacking in >70% of angiographies2 and may be discovered only by intravascular imaging, namely OCT and intravascular ultrasound (IVUS).2,3

Considering the high rate of misdiagnosed SCAD,2–6 an interesting and useful score system (Figure 1) was previously published and tested6–8 allowing interventionists to select suspected cases in which intravascular imaging, particularly OCT, as the first choice, thanks to its higher spatial resolution (about 10 times greater than IVUS, which represents the second line) could identify the presence of SCAD, thus reducing the time to obtain the correct diagnosis and initiate appropriate therapy. The score is in the process of statistical validation on a larger cohort.

Figure 1.
(0,58MB).

Flowchart for the diagnosis and management of spontaneous coronary artery dissection.7

Moreover, SCAD management remains challenging because of the lack of evidence supporting standard medical therapy, and the role of percutaneous or surgical revascularization is strongly debated.4,5,9 Abreu et al. state that, when necessary, a long stent or two stents were implanted, preventing the extension of intramural hematoma caused by stent compression against the vessel wall.

Conservative management (medical therapy) with aspirin, P2Y12 inhibitors, beta-blockers and statins is the preferred option according to a recently published experience-based survey. Alternatively, our group suggested invasive treatment with implantation of a drug-eluting stent or a bioresorbable scaffold (BRS) in cases of dissection involving vessels of ≥3 mm diameter or proximal vessel segments.7

In my opinion, and following our experience6–8,10,11 and the recent literature,12,13 these patients are eligible for bioresorbable scaffolding that allows vessel sealing, in consideration of the typical absence of atherosclerotic plaque rupture and the young age of most subjects affected, as in the cases reported, thus avoiding a permanent metal prosthesis.

In conclusion, our clinical-angiographic score could have helped provide the correct diagnosis, especially in challenging cases, thus allowing effective therapy that in my opinion should have been invasive, preferably with BRS implantation, considering the clinical presentation of ACS and for lesions longer than 3 mm or involving the proximal segment of coronary arteries, in view of the risk of potentially life-threatening complications that could have occurred in young people like the patients of the case series reported.

Conflicts of interest

The author has no conflicts of interest to declare.

References
[1]
G. Abreu, C. Galvão Braga, J. Costa
Spontaneous coronary artery dissection: a single-center case series and literature review
Rev Port Cardiol, 37 (2018), pp. 707-713 http://dx.doi.org/10.1016/j.repc.2017.07.019
[2]
J. Saw, G.B.J. Mancini, K. Humphries
Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging
Catheter Cardiovasc Interv, 87 (2016), pp. E54-E61 http://dx.doi.org/10.1002/ccd.26022
[3]
F. Alfonso, M. Paulo, N. Gonzalo
Diagnosis of spontaneous coronary artery dissection by optical coherence tomography
J Am Coll Cardiol, 59 (2012), pp. 1073-1079 http://dx.doi.org/10.1016/j.jacc.2011.08.082
[4]
A. Yip, J. Saw
Spontaneous coronary artery dissection – a review
Cardiovasc Diagn Ther, 5 (2015), pp. 37-48 http://dx.doi.org/10.3978/j.issn.2223-3652.2015.01.08
[5]
J. Saw, G.B. Mancini, K.H. Humphries
Contemporary review on spontaneous coronary artery dissection
J Am Coll Cardiol, 68 (2016), pp. 297-312 http://dx.doi.org/10.1016/j.jacc.2016.05.034
[6]
D. Buccheri, D. Piraino, R.A. Latini
Spontaneous coronary artery dissections: a call for action for an underestimated entity
Int J Cardiol, 214 (2016), pp. 333-335 http://dx.doi.org/10.1016/j.ijcard.2016.03.131
[7]
D. Buccheri, D. Piraino, G. Andolina
Score system approach to diagnose and manage spontaneous coronary artery dissection
Rev Esp Cardiol, 69 (2016), pp. 878-879 http://dx.doi.org/10.1016/j.rec.2016.05.007
[8]
D. Buccheri, D. Piraino, B. Cortese
Intravascular imaging as a tool for definite diagnosis of acute coronary syndrome caused by spontaneous coronary artery dissection
Int J Cardiol, 214 (2016), pp. 43-45 http://dx.doi.org/10.1016/j.ijcard.2016.03.114
[9]
G. Quadri, E. Cerrato, J. Escaned
Importance of close surveillance of patients with conservatively managed spontaneous coronary artery dissection
JACC Cardiovasc Interv, 11 (2018), pp. e87-e89 http://dx.doi.org/10.1016/j.jcin.2018.03.020
[10]
D. Buccheri, G. Zambelli, F. Alfonso
Pulse on spontaneous coronary artery dissections: experience-based survey
JACC Cardiovasc Interv, 10 (2017), pp. 1469-1471 http://dx.doi.org/10.1016/j.jcin.2017.05.039
[11]
D. Buccheri, G. Zambelli
Focusing on spontaneous coronary artery dissection: actuality and future perspectives
J Thorac Dis, 8 (2016), pp. E1784-E1786 http://dx.doi.org/10.21037/jtd.2016.12.79
[12]
A. Ielasi, B. Cortese, G. Tarantini
Sealing spontaneous coronary artery dissection with bioresorbable vascular scaffold implantation: data from the prospective “Registro Absorb Italiano” (RAI Registry)
Int J Cardiol, 212 (2016), pp. 44-46 http://dx.doi.org/10.1016/j.ijcard.2016.03.043
[13]
G. Quadri, F. Tomassini, E. Cerrato
First reported case of magnesium-made bioresorbable scaffold to treat spontaneous left anterior descending coronary artery dissection
Catheter Cardiovasc Interv, 90 (2017), pp. 768-772 http://dx.doi.org/10.1002/ccd.27214
Copyright © 2018. Sociedade Portuguesa de Cardiologia
Idiomas
Revista Portuguesa de Cardiologia

Receba a nossa Newsletter

Opções de artigo
Ferramentas
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos