Spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare, but very important clinical phenomenon usually described as an uncommon cause of an acute coronary artery syndrome. It typically affects young healthy people, predominantly female, and is usually diagnosed postmortem. The overall incidence of spontaneous coronary artery dissection in coronary angiograms ranges from 0.1 to 1.1%. However, routine coronary angiography in acute coronary syndromes has demonstrated that the true incidence of this phenomenon is underestimated. The pathophysiology is unclear, and clinical presentation usually demonstrates great variability. However, three types of spontaneous coronary artery dissection have been recognized: atherosclerotic, puerperal, and idiopathic. The appropriate treatment of spontaneous coronary artery dissection is difficult, and there is no clinical consensus on the appropriate management of these patients. Reports from the literature suggest that stable patients with limited dissections demonstrate spontaneous healing with medical management alone. Recent evidence has shown an improved prognosis after urgent restoration of the coronary flow by percutaneous intervention or coronary artery bypass surgery. Reports of uncontrolled escalating coronary dissections, extension of intramural hematoma, and acute coronary thrombosis after stenting mark this method as controversial. Thus, the decision making process for the appropriate management should respect evidence based medicine and have an individual approach to each patient alone. Clinical perspectives of the spontaneous coronary artery dissection are analyzed in this review article, based on personal experience and recently published literature.