Search Results (59)

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) are two conditions presenting as acute coronary syndromes that predominantly affect women and are frequently triggered by emotional or physical stress. While traditionally considered distinct entities, emerging evidence suggests that these conditions may coexist more frequently than previously recognized, sharing common pathophysiological mechanisms centered on catecholamine-mediated pathways, vascular vulnerability, and hormonal influences. Their overlapping presentations create significant diagnostic challenges that may lead to misdiagnosis and suboptimal management. This narrative review examines the pathophysiological convergence between SCAD and TTS, addresses the diagnostic complexity arising when these entities coexist, and proposes a novel stepwise diagnostic algorithm integrating clinical risk stratification, coronary angiography, intracoronary imaging, and cardiac magnetic resonance imaging. The review also provides scenario-dependent management guidance and outlines priorities for future research. Full article

Cardiovascular disease remains the leading cause of mortality among women worldwide, yet coronary syndromes in women continue to be under-recognized and insufficiently represented in clinical research. This review summarizes sex-specific pathophysiological mechanisms, risk factors, clinical presentation, and management considerations in women with coronary syndromes. Women are more likely than men to present with non-obstructive and non-atherosclerotic ischemic phenotypes, including ischemia or angina with non-obstructive coronary arteries, coronary microvascular dysfunction, myocardial infarction with non-obstructive coronary arteries, spontaneous coronary artery dissection, vasospastic angina, and Takotsubo syndrome. These entities often require diagnostic strategies beyond the detection of flow-limiting epicardial stenosis, including cardiac magnetic resonance imaging, intracoronary imaging, and coronary function testing. Traditional cardiovascular risk factors remain important, but several female-specific risk enhancers, including premature menopause, adverse pregnancy outcomes, polycystic ovary syndrome, autoimmune disease, and psychosocial stressors, further modify risk and remain incompletely integrated into routine clinical assessment. Women may also experience diagnostic delays due to symptom misclassification, lower baseline troponin concentrations, and clinical algorithms historically derived from male-predominant populations. Management should follow guideline-directed therapy when appropriate, while recognizing sex-related differences in pharmacology, bleeding risk, revascularization outcomes, and the need for phenotype-specific treatment in INOCA, MINOCA, SCAD, and Takotsubo syndrome. Finally, transgender and gender-diverse individuals remain largely absent from cardiovascular trials, highlighting the need for inclusive research frameworks that distinguish sex, gender identity, and hormone exposure. Improved recognition of sex- and gender-related differences is essential to advance equitable cardiovascular care. Full article

Background: Patients with spontaneous coronary artery dissection (SCAD) are at increased risk of cardiovascular events, including dissection in other arterial territories such as cervical arteries. Those with combined coronary and cervical arterial dissection (CACAD) may have more widespread arterial abnormalities and worse outcomes, underscoring the need for better risk stratification and personalized care. Objective: This study examined the prevalence of cervical artery dissection (CvAD) in patients diagnosed with SCAD, evaluated potential risk factors for developing CvAD, and assessed their impact on clinical outcomes, including all-cause mortality, SCAD recurrence, and stroke. The goal was to enhance risk stratification by identifying SCAD patients at increased risk for CvAD. Design: In this retrospective cohort study, patients diagnosed with SCAD between 2018 and 2024 across Mayo Clinic sites were identified using ICD-10 codes. Manual chart review confirmed CvAD diagnoses. Patients were stratified based on the presence or absence of CvAD. Chi-square and independent t-tests were used to compare risk factors and comorbidities. Univariate screening and multivariable logistic regression were used to identify predictors of CvAD. Results: Among 1380 patients with SCAD, 131 (9.5%) had CvAD. The median follow-up was 2.02 years (IQR: 1.1–5.2 years). All CvAD diagnoses were identified after the index SCAD event through systematic post-SCAD vascular imaging. The mean age was similar between groups (51.5 ± 11.3 years in CACAD vs. 50.9 ± 10.7 years in SCAD-only, p = 0.540), and the majority were female (93.9% vs. 91.9%, p = 0.529). Multivariable regression identified extremity arterial dissection (OR: 8.13, 95% CI: 3.41–19.36, p < 0.001), fibromuscular dysplasia (FMD) (OR: 7.52, 95% CI: 4.67–12.10, p < 0.001), connective tissue disorders (CTDs) (OR: 6.85, 95% CI: 2.35–19.98, p < 0.001), and anxiety (OR: 1.69, 95% CI: 1.01–2.81, p = 0.044) as significant predictors of CvAD. CvAD was a strong independent predictor of stroke (OR: 6.37, 95% CI: 2.93–13.87, p < 0.001). Mortality and SCAD recurrence did not differ significantly between groups. Conclusions: Patients with CACAD demonstrate a systemic vascular phenotype with significantly higher rates of FMD, connective tissue disease, extremity arterial dissection, and stroke. These findings highlight the importance of comprehensive vascular screening and individualized monitoring in at-risk SCAD patients. Full article

Myocardial infarction with non-obstructive coronary arteries (MINOCA) accounts for approximately 5–15% of all myocardial infarctions and disproportionately affects women. Once treated as a diagnosis of exclusion, MINOCA is now recognised as a heterogeneous, mechanism-based syndrome encompassing atherosclerotic plaque disruption, epicardial and microvascular vasospasm, microvascular dysfunction, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD). Despite the absence of obstructive disease, it carries substantial morbidity and mortality, underscoring the need for accurate aetiological characterisation and tailored therapy. Our aim is to review the contemporary evidence of the role of advanced imaging modalities—cardiac magnetic resonance imaging (CMR), optical coherence tomography (OCT), intravascular ultrasound (IVUS) and invasive functional testing—in the diagnosis, prognostic stratification, and therapeutic guidance of patients with MINOCA. CMR is the non-invasive reference standard for differentiating true ischaemic MINOCA from non-ischaemic mimics such as myocarditis and Takotsubo syndrome, reclassifying the working diagnosis in up to two-thirds of cases. OCT and IVUS provide intracoronary characterisation of culprit substrates that are invisible via angiography, particularly plaque rupture, erosion, intramural haematoma and SCAD, while acetylcholine and adenosine testing identify endothelium-dependent vasospasm and endothelium-independent microvascular dysfunction respectively. Coronary Computed Tomography Angiography (CCTA) could also play an additional role in the diagnosis of epicardial CAD. Each modality additionally carries independent prognostic value, with abnormal findings consistently linked to higher rates of major adverse cardiovascular events. The recently completed PROMISE trial provided the first randomised evidence that stratified, imaging-guided treatment might have some positive impact on angina status and quality of life compared with empirical standard care. In conclusion, advanced imaging has transformed MINOCA from a diagnosis of exclusion into a mechanism-based syndrome amenable to personalised therapy. Broader integration of these modalities into routine practice, supported by further randomised trials, is needed to optimise outcomes. Full article

Background: Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndrome (ACS), and recent studies have shown a significant involvement in young women with few or no cardiovascular risk factors. The pathogenesis is multifactorial, possibly related to genetic causes, hormonal imbalances or peripartum. Methods and results: A 45-year-old woman was admitted to the emergency room for anterior myocardial infarction. Coronary angiography showed a long, diffuse tapering involving mid to distal left anterior descending (LAD) segments, with haziness in the mid-LAD. Intravascular ultrasound was used, highlighting the presence of intramural hematoma and leading to medical management. Hematological samples revealed a diagnosis of hyperthyroidism; this detection prompted an evaluation of a possible association with SCAD. Echocardiography revealed a preserved ejection fraction with akinetic apex and a sessile thrombus leading to anticoagulant with warfarin. Discussion: SCAD is a rare cause of ACS, difficult to recognize and whose physiopathology is not fully understood. In our case report we highlight the possible link between SCAD and hyperthyroidism. The lack of specific guidelines, the concomitant presence of hyperthyroidism and apical thrombus forced us toward a multidisciplinary management approach, with a meticulous evaluation of risks and benefits to offer the best therapeutic option. Full article

Background: the pathophysiological mechanisms underlying spontaneous coronary artery dissection (SCAD) remain incompletely understood. Inflammation may play a pivotal role by promoting vascular susceptibility to SCAD. This study aimed to evaluate pericoronary adipose tissue (PCAT) attenuation, a recognized imaging marker of vascular inflammation, in patients with SCAD. Methods: patients with SCAD who underwent coronary computed tomography angiography (CCTA) within 48 h of the index event and with an identifiable trigger were included. Patients were classified according to the trigger preceding the event (emotional vs. physical). PCAT attenuation was measured in culprit and non-culprit vessels in all patients. Results: A total of 25 SCAD patients were included (mean age 55 ± 11 years, 80.0% female). Emotional triggers were reported in 17 patients (68.0%), while 8 (32.0%) experienced a physical trigger. Type 2 dissections were more common in the emotional trigger group (64.7% vs. 25.0%, p = 0.040). Patients with emotional triggers exhibited higher PCAT attenuation compared with those with physical triggers in the SCAD-related vessel (−62.35 ± 6.46 HU vs. −70.86 ± 8.45 HU; p = 0.028) and in non-culprit vessels (−61.39 ± 7.24 HU vs. −71.16 ± 5.28 HU; p = 0.001). Conclusions: patients with SCAD demonstrated elevated PCAT attenuation, particularly in those with emotional triggers, in both culprit and non-culprit vessels. These findings suggest that vascular inflammation may represent a predisposing factor for SCAD and a target for preventive and therapeutic strategies. Full article

Spontaneous coronary artery dissection (SCAD) is an important non-atherosclerotic cause of acute coronary syndrome, predominantly affecting younger women without traditional cardiovascular risk factors. In hemodynamically stable patients, accumulating evidence supports a conservative management strategy owing to the high rate of spontaneous vessel healing, while technically challenging invasive interventions should be reserved for selected high-risk cases. Despite growing evidence regarding acute management, recurrent SCAD and other adverse cardiovascular events have been reported during follow-up, underscoring the need for surveillance. However, optimal strategies for post-acute follow-up and for assessing the appropriateness of treatment decisions remain insufficiently established. This review focuses on clinical decision-making in the management of SCAD, with particular emphasis on follow-up assessment. We summarize the existing evidence regarding indications for conservative versus invasive treatment and discuss the clinical rationale for longitudinal imaging surveillance. Special attention is given to the role of non-invasive follow-up using coronary computed tomography angiography, including confirmation of vessel healing, evaluation of residual intramural hematoma, and assessment of distal coronary flow. Given the heterogeneity of SCAD and the risk of recurrence, individualized treatment decisions and structured follow-up strategies are essential to optimize management, avoid unnecessary invasive procedures, and support care and risk stratification in patients with SCAD. Full article

Factor XII (FXII) deficiency is a coagulation factor disorder inherited in an autosomal recessive manner that causes prolonged activated partial thromboplastin time (aPTT). Although it is clinically benign without additional bleeding risk, it has been associated with paradoxical thrombosis. We report the case of a 38-year-old woman who presented with cardiac arrest secondary to spontaneous coronary artery dissection (SCAD) in the absence of identifiable risk factors. Laboratory investigations revealed an isolated prolonged aPTT, which was corrected with mixing studies, and a severe FXII deficiency with activity levels < 1%. Molecular analysis identified two homozygous FXII gene variants: the 46C>T polymorphism and the c.619G>C (p.Ala207Pro) variant. The two variants are considered clinically benign, although the combination of both in a single individual has not been previously reported. The coexistence of FXII deficiency in this case may be of clinical and hypothesis-generating interest. Full article

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a heterogeneous clinical entity encompassing multiple ischemic mechanisms, including atherosclerotic plaque disruption, coronary artery spasm, coronary microvascular dysfunction, coronary embolism, and spontaneous coronary artery dissection. Despite the absence of obstructive coronary disease, patients with MINOCA remain at substantial risk of adverse cardiovascular outcomes, underscoring the need for accurate early diagnosis and effective risk stratification. In this context, accumulating evidence indicates that circulating serum biomarkers may provide additional pathophysiological and prognostic insights in patients with a working diagnosis of MINOCA. Moreover, distinct biomarker profiles may help support the differential diagnostic evaluation between MINOCA and other causes of acute myocardial injury, such as myocardial infarction with obstructive coronary arteries, myocarditis, and Takotsubo syndrome. This narrative review summarizes current evidence on serum biomarkers in MINOCA, highlights their potential role in guiding tailored diagnostic strategies, and discusses future perspectives toward biomarker-driven precision medicine in patients presenting with acute myocardial injury. Full article

Background/Objectives: Migraine is a leading cause of disability in women and is intricately linked to hormonal fluctuations and systemic health. This review aims to unravel the complex relationship between migraine, cardiovascular disease, and metabolic syndrome throughout the female reproductive lifespan. Methods: A comprehensive narrative review was conducted using the PubMed database for studies published between January 1988 and December 2025. Keywords included “migraine”, “cardiovascular risk”, “metabolic syndrome”, “pregnancy”, and “hormonal therapy”. Articles were selected to synthesize the latest pathophysiological evidence and clinical guidelines. Results: Migraine prevalence in women is two to threefold higher than in men, peaking during fertile age. Hormonal milestones, particularly estrogen withdrawal, trigger menstrual migraine. Metabolic syndrome is significantly more common in migraineurs than the general population. Obesity and insulin resistance have been associated with higher migraine attack frequency and severity. Experimental evidence suggests that hyperinsulinemia may sensitize TRPV1 receptors on trigeminal neurons and enhance CGRP release, potentially lowering the activation threshold for migraine attacks; however, direct confirmation of this pathway in humans remains limited. Furthermore, migraine with aura is linked to a doubled risk of ischemic stroke and increased risk of cardiovascular events. In pregnancy, migraine is an independent risk factor for stroke, myocardial infarction, and spontaneous coronary artery dissection. Conclusions: Migraine is a critical marker for cardiovascular and metabolic risk, necessitating routine screening and multidisciplinary management. Clinicians must prioritize cardiovascular counselling, metabolic evaluations, and careful monitoring in these patients, especially during pregnancy. Hormonal therapy choices should be individualized, preferring progestin-only contraceptives for those with aura and transdermal routes for hormone replacement therapy to minimize cardiometabolic impact. Full article

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndromes in younger women without typical atherosclerotic risk factors. Its distinct pathophysiology and vessel fragility create unique challenges for revascularization. Conservative management is preferred when hemodynamics and coronary flow permit, but selected cases necessitate intervention, primarily percutaneous coronary intervention (PCI). Despite growing insights into SCAD pathomechanics—the “outside-in” and “inside-out” hypotheses—and the central role of intracoronary imaging (OCT/IVUS), optimal device strategies remain under-researched. The present review covers contemporary SCAD-PCI pitfalls and limitations, expanding to the mechanistic underpinnings and procedural applications of drug-coated balloons (DCB) and bioresorbable scaffolds (BRS) as “leave-nothing-behind” alternatives. Both approaches have advantages and drawbacks but are attractive in selected scenarios: DCB delivers antiproliferative therapy without permanent caging, and BRS provides temporary scaffolding (amenable to overlap when required) with the potential to restore biomechanics/vasomotion after resorption. Acknowledging that definitive evidence is lacking and current data are largely observational, the review finally sets future research priorities including head-to-head trials of different DCB types and evaluation of next-generation, thinner-strut, predictably resorbing BRS. The overarching question is whether—and how—these modalities can be integrated into standardized, imaging-guided interventional algorithms for SCAD. Full article

The use of imaging during percutaneous coronary intervention (PCI) can improve the outcomes by giving key information in every phase of the procedure. It can improve the knowledge of plaque composition thus helping the subsequent technical strategy; it can precisely define the measure of the stent to implant; it can assess in detail the correct positioning of the stent (apposition, expansion, and full coverage of the atherosclerotic plaque); it helps in recognizing the complications that may occur after stenting (e.g., edge dissection or tissue/thrombus protrusion in the stent area). Further, it could help evaluation for both diagnostic and therapeutic purposes of angiographic unknown or questionable findings [e.g., spontaneous coronary artery dissection (SCAD), characterization of mycotic aneurysm and pseudoaneurysm]. In the follow up phase, the use of intracoronary imaging may significantly improve the understanding of the mechanisms leading to the procedural failure. What this review adds is to describe the similarities and differences between intravascular ultrasound (IVUS) and optical coherence tomography (OCT) technologies, to highlight the evidence supporting their utility to improve PCI outcomes, to give practical advice and tools on daily interventional routine, to show a point of view on future perspectives and integration with artificial intelligence (AI). Full article

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome, characterized by the development of a false lumen within the coronary arterial wall, leading to narrowing or complete occlusion of the true lumen. This underrecognized condition accounts for a substantial proportion of sudden cardiac death (SCD), particularly among young, otherwise healthy women. Macroscopically, SCAD is defined by intramural hematoma and focal thickening of the arterial wall, while histological examination demonstrates separation of the tunica media, elastic fiber degeneration, and variable inflammatory infiltrates. Proposed pathogenic mechanisms include primary intimal tear and primary intramural hematoma, frequently associated with predisposing conditions such as fibromuscular dysplasia, connective tissue disorders, and specific hormonal states. In cases of myocardial infarction, the myocardium exhibits acute ischemic necrosis and early hypoperfusion injury. Postmortem diagnosis requires meticulous coronary dissection, adjunctive histochemical and immunohistochemical staining, and, when indicated, molecular autopsy (MA). The purpose of this review is to provide an updated synthesis of current knowledge on SCAD as a cause of SCD, integrating pathogenetic, morphological, and genetic perspectives, and to emphasize the role of MA as both a diagnostic and preventive tool. Full article

Background: Myocardial infarction (MI) in young adults, once a rarity, is increasingly recognized as a distinct clinical entity. Unlike traditional MI patients, younger individuals often present without established risk factors or advanced atherosclerosis, prompting a reevaluation of pathophysiologic paradigms and risk assessment strategies. Objective: This review synthesizes current evidence on the epidemiology, pathophysiology, and diagnostic challenges of MI in adults under 55 years, with emphasis on risk factor profiles. We distinguish between traditional cardiovascular risk factors—smoking, dyslipidemia, hypertension, diabetes, obesity, and family history—and emerging contributors, including elevated lipoprotein(a), recreational drug use (cocaine, cannabis, amphetamines), autoimmune and inflammatory conditions, psychosocial stress, sleep disorders, genetic predisposition, and non-atherosclerotic mechanisms such as myocardical infarction with non-obstructive coronary arteries, spontaneous coronary artery dissection, SCAD and Takotsubo syndrome. Methods: A narrative literature review was conducted, focusing on studies from the last five years addressing MI in young adults, including data from large registries, cohort studies, and recent experimental findings. Full article

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized, non-atherosclerotic cause of acute coronary syndrome (ACS), particularly in younger women. This comprehensive review outlines SCAD’s unique pathophysiology, which is linked to underlying arteriopathies like fibromuscular dysplasia, and highlights the critical role of advanced intravascular imaging for accurate diagnosis. A fundamental shift in management is detailed, with evidence favoring a conservative strategy for stable patients due to high rates of spontaneous vessel healing, reserving technically challenging invasive interventions for high-risk cases. Importantly, this review also addresses long-term outcomes, noting significant rates of recurrence and Major Adverse Cardiac Events (MACE), a high prevalence of persistent chest pain, and the central role of beta-blocker therapy in secondary prevention. Ultimately, SCAD requires a departure from standard ACS protocols towards a personalized approach that emphasizes accurate diagnosis, cautious initial management, and vigilant long-term follow-up. Full article