Acute spontaneous coronary artery dissection (SCAD) is believed to be a major cause of heart attacks in women under the age of 60. This coronary tear is 4 times more common than in humans and is mainly caused by stress.
According to one new study presented at the European Congress of Cardiology, the ESC 2018, the “acute and spontaneous dissection of the coronary arteries”, a cause of infarction considered to be very unusual in men, would on the contrary be frequent in young women. This acute and spontaneous dissection of the coronary arteries (SCAD) is thought to be the cause of about a third of heart attacks in women under the age of 60.
“Fibro-muscular dysplasia”, an anomaly of the coronary arteries more common in women than in men, is a favorable area which plays a major role. Finally, emotional stress appears to be a major trigger for spontaneous coronary artery dissection.
An unusual cause of heart attack
Spontaneous coronary artery dissection (SCAD) occurs when the inner wall of an artery tears and separates from the outer wall of the artery. The blood from the arteries enters the tear, spreads into the space produced between the 2 walls, enlarges and forms a clot which, in fine, narrows the lumen of the artery and blocks blood flow.
Symptoms are similar to those of a heart attack and include chest pain, palpitations, pain in the arms, shoulders, or jaw, as well as nausea, shortness of breath, abnormal sweating, and a feeling of headache. empty.
The treatment aims to restore blood circulation to the torn coronary artery as quickly as possible, in order to re-irrigate the heart muscle and prevent necrosis. Some patients only receive drugs, while others benefit from a coronary angiography in order to find a way to re-open the artery, either with a stent or by bypassing the artery.
A Canadian prospective study
The Canadian SCAD study examined the clinical presentation, natural history, treatment, and outcome of acute and spontaneous coronary artery dissection (SCAD).
The researchers prospectively recruited, between 2014 and 2018, 750 people with SCAD in 20 centers in Canada and two in the United States. The diagnosis of acute and spontaneous dissection of the coronary arteries was systematically confirmed in a reference angiography center.
The patients were followed for three years to assess the occurrence of major adverse cardiovascular events (MACE) following acute and spontaneous dissection of the coronary arteries.
Frequency of fibromuscular dysplasia
Among the possible causes of the acute and spontaneous dissection of the coronary arteries, about half of the people analyzed (49%) reported emotional stress before the event and 30% reported physical stress (in 10% of cases, weight lifted exceeded 23 kg).
The most common predisposing factor is fibromuscular dysplasia (40% of cases evaluated), which consists of abnormal growth of cells in the arteries and which can lead to narrowing (stenosis), aneurysms or tears (dissections).
The other predisposing factors are: an obstetric history including five or more pregnancies (10%), the period around childbirth (5.3%), fertility treatment (5.1%), general inflammatory diseases (4 , 7%) and connectivitis (3.5%).
Acute pain syndrome
All patients experienced acute coronary syndrome upon acute spontaneous coronary artery dissection, 99.3% having had a heart attack and 0.7% having unstable angina. The main symptom is chest pain which is seen in nine out of ten patients. In angiography, the left anterior coronary artery is the artery most often affected (52%) and a prolonged diffuse narrowing of the coronary artery is the most common form (called SCAD type 2; 58%).
The majority of patients were treated with medication alone (85%), while 14% had percutaneous coronary angioplasty and less than 1% had coronary bypass surgery.
A more common cause in women
Almost all patients (99.9%) are alive to 30 days. The frequency of 30-day MACE-type cardiovascular events is 7.5% (including recurrent heart attack in 5.1%, cardiac arrest in 3.3%, unplanned revascularization in 2.1%, severe heart failure in 1.5%, mechanical hemodynamic support in 1.5%, stroke in 1.2%, heart transplantation in 0.1% and death in 0.1% of patients). Within 30 days of the leave, 5.1% have a 2e emergency room visit and 2.5% are admitted for chest pain. These early recurrences testify to a real problem of treatment of these acute and spontaneous dissections of the coronary arteries which could be responsible for the poorer results of the management of myocardial infarction in women compared to men.
A call for research on treatment
Study presenter Professor Jacqueline Saw, University of British Columbia, Vancouver, Canada, said: “Coronary artery dissections were previously underestimated and considered rare. Coronary imaging has improved the diagnosis, but we still know very little about the cause and natural history of acute and spontaneous coronary artery dissection. “
This study shows that the acute and spontaneous dissection of the coronary arteries, where fibromuscular dysplasia plays a major role, mainly affects middle-aged women. More research is needed to determine the most appropriate treatment for these patients who have a heart attack that does not follow as well as in men.
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