Today we discussed the case of a young woman with recurrent chest pain who was eventually found to have a spontaneous coronary artery dissection (SCAD).

First, we discussed causes of chest pain in young patients

  • Noncardiac causes (GERD, MSK, esophageal spasm, etc)
  • ACS
  • Pericarditis/myopericarditis
  • Pulmonary embolism
  • Coronary vasospasm
  • Takotsubo CM
  • Aortic dissection
  • SCAD

Up to 30% of MIs in women <50 are thought to be due to SCAD.

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Treatment of SCAD is conservative

  • Consider anticoagulation in order to maintain patency of the true lumen. This is in contrast to aortic dissections, where anticoagulation should be avoided in order to prevent expansion of the false lumen
  • Anti-ischemic therapy (BBs, CCBs)
  • Single or dual antiplatelet therapy
  • There is generally no role for PCI, as dissections often heal on their own, and mechanical manipulation can worsen the dissection

We also talked about acute aortic syndromes, of which there are three main kinds:

  1. Aortic dissection
  2. Intramural hematoma (IMH)
  3. Penetrating atherosclerotic ulcer (PAU)
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Baliga et al. The Role of Imaging in Aortic Dissection and Related Syndromes. JACC: Cardiovascular Imaging 2014.

Workup of suspected aortic syndromes

  • Dx: CXR, EKG, D-dimer, troponin, drug screen (looking for cocaine)
  • Consider an arterial line
  • Imaging: consider CTA, TTE vs TEE
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Imaging modalities for acute aortic syndromes

Management

  • Anti-impulse therapy: lower the velocity of LV contraction to minimize lesion progression
    • Esmolol, labetalol; can consider CCBs if BBs not tolerated
    • Nicardipine, nitroprusside
  • Pain control (inadequate pain control worsens outcomes)
  • Early surgical consultation
    • Type A lesions typically require surgery
    • Type B lesions can usually be managed medically

References

  1. Mukherjee D. Acute Aortic Syndromes: Diagnosis and Management. JACC 2017.
  2. Baliga et al. The Role of Imaging in Aortic Dissection and Related Syndromes. JACC 2014.
  3. Saw et al. Contemporary Review on SCAD. JACC 2016.

 

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