By Michael H. Crawford, MD, Editor
SYNOPSIS: When viewing cardiac MRI and peripheral angiography of patients with spontaneous coronary artery dissection, investigators observed peripheral arterial abnormalities, including fibromuscular dysplasia, in about one-quarter.
SOURCE: Androulakis E, Azzu A, Papagkikas P, et al. Spontaneous coronary artery dissection: Insights from cardiac magnetic resonance and extracoronary arterial screening. Circulation 2022;145:555-557.
Spontaneous coronary artery dissection (SCAD) is a rare entity that is difficult to diagnose and can lead to catastrophic consequences. Usually, clinicians make the diagnosis with invasive angiography because of their suspicion about acute myocardial infarction (MI). However, unless the flow in the involved artery is severely compromised, the recommendation is to not intervene, as this can lead to further dissection and poor outcomes. Another issue is learning some of these patients have arteriopathy of extracoronary arteries, which could be problematic in the future. It may be best to screen for extracoronary involvement in SCAD patients, but little data exist on the clinical value of such a practice.
To put this issue into perspective, investigators from the Royal Brompton Hospital in London conducted a retrospective observational study of 144 survivors of SCAD older than age 18 years. Most were women (88%) with a mean age of 49 ± 11 years. In 75 patients, a complete cardiac MRI study, along with peripheral and cranial vascular imaging, was performed. These 75 patients were the focus of this study, the aim of which was to exhibit the prevalence, pattern, and size of the MI and its effect on cardiac function, and to present data on screening for extracoronary arteriopathy.
The left anterior descending artery was the culprit in 61%, the left main in 5.5%, and multivessel involvement in 17%. A MI was present in 64%, 83% of whom showed a single territory involved. Fibrosis detected by late gadolinium enhancement involved an average of 8% of the total myocardial mass, but 29% had > 10% of the myocardium fibrosed and 11% had > 20% fibrosed. SCAD was associated with pregnancy in 11 of 75 patients with cardiac MRI (7.5%), all of whom experienced a MI and underwent a coronary intervention. Also, these patients experienced worse MIs compared to the rest of the cohort (25% of the myocardial mass vs. 6.6%; P < 0.001) and lower left ventricular ejection fractions (51% vs. 64%; P < 0.001).
Peripheral artery involvement was present in 27% of the entire cohort with peripheral imaging. One-quarter of these revealed fibromuscular dysplasia (FMD). Severe tortuosity was seen in 30% of those with peripheral disease detected (25% showed fusiform dilatation of the aorta, 25% showed focal stenoses, and 20% showed ectasia). Interestingly, almost three-quarters of patients with peripheral disease detected experienced a MI (OR, 7.0; 95% CI, 0.9-57.5; P = 0.04).
In addition, patients without peripheral vascular disease detected were more likely to be diagnosed with single vessel coronary disease (OR, 4.0; 95% CI, 1.3-12.7; P = 0.015). Accordingly, after multivariate adjustment for baseline characteristics, such as age, sex, and body surface area, multiterritory MI was independently associated with the detection of peripheral vascular disease. The authors concluded the cardiac MRI with peripheral vessel angiography is a valuable contribution to the evaluation of SCAD patients and may carry implications for their long-term follow-up.
COMMENTARY
Although not a large study, this might be one of the largest cohorts of SCAD patients screened for peripheral artery involvement by MR angiography. Two-thirds of SCAD patients exhibited single vessel left anterior descending or left main coronary involvement. Two-thirds of all SCAD patients experienced a MI. All pregnancy-associated SCAD patients experienced a MI — and these all were worse than those in the rest of the cohort. This translated to lower left ventricular ejection fraction in these patients. About one-quarter of the cohort demonstrated peripheral artery involvement, and one-quarter of those patients had FMD. Finally, multiterritory MI was independently associated with peripheral artery disease.
This was a small study derived from a single center in the United Kingdom. Peripheral MR angiography was available only for about half the entire SCAD population. There are no follow-up data to address the potential future outcomes of the coronary or peripheral disease detected. Also, it would be interesting to know why patients without MI underwent invasive angiography. Likewise, why did half the patients undergo peripheral angiography? Some selection biases may be present here. Further, there were no data on which peripheral arterial beds were involved.
Despite these limitations, it seems reasonable for clinicians to watch for peripheral artery involvement in SCAD patients, especially those who present with multiterritory MI and pregnancy-associated SCAD. MR angiography is an attractive option for this purpose because it is relatively noninvasive, but an argument could be made for imaging peripheral arterial beds after the coronary angiogram in patients who are stable and have no contraindications to further angiography.
When viewing cardiac MRI and peripheral angiography of patients with spontaneous coronary artery dissection, investigators observed peripheral arterial abnormalities, including fibromuscular dysplasia, in about one-quarter.
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