Spontaneous coronary artery dissection diagnostic approach

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Spontaneous Coronary Artery Dissection Microchapters



Historical Perspective




Differentiating Spontaneous coronary artery dissection from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Diagnostic Approach

History and Symptoms

Physical Examination

Laboratory Findings






Other Imaging Findings

Other Diagnostic Studies


Treatment Approach

Medical Therapy

Percutaneous Coronary Intervention


Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Type 1

Type 2A

Type 2B

Type 3

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Synonyms and keywords: SCAD


Coronary angiography is the standard for diagnosing spontaneous coronary artery dissection. Adjunctive imaging modalities such as intravascular ultrasonography (IVUS), optical coherence tomography (OCT), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) may offer complementary details for establishing a definitive diagnosis.

Algorithm for Diagnosis of Spontaneous Coronary Artery Dissection in the Setting of Acute Coronary Syndrome: A Scientific Statement From the American Heart Association

Algorithm for diagnosis of spontaneous coronary artery dissection (SCAD) in the setting of acute coronary syndrome.[1]

Coronary angiography after intracoronary nitrates
Type 1 SCAD
(arterial wall stain, multiple lumens)
Type 2 SCAD
(intramural hematoma, diffuse, smooth stenoses)
Type 3 SCAD
(mimics atherosclerosis)
If diagnostic uncertainty, consider adjunctive diagnostic strategies:
❑  OCT/IVUS if feasible/safe
❑  CT coronary angiography
❑  CTA/MRA/angiographic imaging for extracoronary vasculopathy/FMD
❑  Repeat coronary angiography at 6–8 weeks

Abbreviations: CT, computed tomography; CTA, computed tomography angiography; FMD, fibromuscular dysplasia; IVUS, intravascular ultrasonography; MRA, magnetic resonance angiography; OCT, optical coherence tomography.

Algorithm for Angiographic Diagnosis of Non-Atherosclerotic Spontaneous Coronary Artery Dissection

Algorithm for the Angiographic Diagnosis and Confirmation of Spontaneous Coronary Artery Dissection[2]


Presence of features that raise suspicion for SCAD?
(click for details)

❑  Myocardial infarction in young women (age ≤50)

❑  Absence of traditional cardiovascular risk factors

❑  Little or no evidence of coronary atherosclerosis

❑  Peripartum state

❑  History of fibromuscular dysplasia

❑  History of connective tissue disorder or systemic inflammation

    ❑  Marfan's syndrome

    ❑  Type 4 Ehlers-Danlos syndrome

    ❑  Loeys-Dietz syndrome

    ❑  Cystic medial necrosis

    ❑  Systemic lupus erythematosus

    ❑  Crohn's disease

    ❑  Ulcerative colitis

    ❑  Polyarteritis nodosa

    ❑  Sarcoidosis

    ❑  Churg-Strauss syndrome

    ❑  Wegener's granulomatosis

    ❑  Rheumatoid arthritis

    ❑  Giant cell arteritis


Perform early coronary angiography


Presence of type 1 SCAD lesion characteristics?
(click for details)

❑  Contrast staining of arterial wall

❑  Multiple radiolucent lumens

❑  Contrast hang-up or slow clearing from the lumen

Type 1 SCAD most likely

Presence of type 2 SCAD lesion characteristics?
(click for details)

❑  Diffuse lesion (typically >20–30 mm)

❑   Smooth luminal narrowing with varying severity

❑  Involvement of mid to distal segments

Stenosis relieved by intracoronary nitroglycerin?

Look for type 3 SCAD lesion characteristics
(click for details)

❑  Focal or tubular stenosis (typically <20 mm)

❑  Mimics atherosclerosis

❑  Additional features

    ❑  No atherosclerosis in other arteries

    ❑  Long lesions (11–20 mm)

    ❑  Hazy stenosis

    ❑  Linear stenosis


Type 3 SCAD most likely

❑  Consider OCT or IVUS for definitive diagnosis

❑  Reassess with angiography in 4 to 6 weeks


Type 2 SCAD most likely

❑  Consider OCT or IVUS for definitive diagnosis

❑  Reassess with angiography in 4 to 6 weeks



  1. Hayes, Sharonne N.; Kim, Esther S.H.; Saw, Jacqueline; Adlam, David; Arslanian-Engoren, Cynthia; Economy, Katherine E.; Ganesh, Santhi K.; Gulati, Rajiv; Lindsay, Mark E.; Mieres, Jennifer H.; Naderi, Sahar; Shah, Svati; Thaler, David E.; Tweet, Marysia S.; Wood, Malissa J. (2018). "Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association". Circulation: CIR.0000000000000564. doi:10.1161/CIR.0000000000000564. ISSN 0009-7322.
  2. 2.0 2.1 Saw J (2014). "Coronary angiogram classification of spontaneous coronary artery dissection". Catheter Cardiovasc Interv. 84 (7): 1115–22. doi:10.1002/ccd.25293. PMID 24227590.