Diagnosis and Treatment of Unrecognized Spontaneous Coronary Artery Dissection in Young Women Presenting With an Acute Coronary Syndrome

Spontaneous coronary artery dissection (SCAD) is often overlooked as a cause of acute coronary syndrome (ACS), particularly in young women. SCAD requires distinct management, underscoring the importance of its timely and accurate diagnosis for effective treatment. This study aims to evaluate the frequency of SCAD underdiagnosis in young women with ACS and pinpoints potential SCAD indicators. All consecutive women ≤55 years with ACS who underwent coronary angiography (CAG) at our tertiary center from 2012 to 2024, were included. Clinical data at baseline and follow-up were retrospectively collected. All coronary angiography's (CAGs) were reviewed for SCAD-signs using the Yip-Saw criteria. Accurately diagnosed SCAD patients were compared to those with initially unrecognized SCAD and patients with other ACS causes. Of 394 patients (mean age 48.4 ± 5.8 years) evaluated, 23% (n = 92) had SCAD, but 41% (n = 38) were not initially correctly diagnosed. SCAD type 3 was most often missed. SCAD patients were younger and more frequently lacked traditional cardiovascular risk factors. They also showed higher coronary tortuosity scores, which were significantly associated with SCAD in multivariate analysis. Invasively treated SCAD patients received more stents than non-SCAD patients, largely due to hematoma extension. Follow-up revealed fewer atherosclerotic ACS in SCAD patients, with recurrent SCAD occurring only in undiagnosed cases. In conclusion, underdiagnosis of SCAD in young women with ACS is common and leads to inappropriate treatment, highlighting the need for increased awareness and improved diagnostic approaches. Young ACS patients with minimal cardiovascular risk factors and high coronary tortuosity scores should be carefully evaluated for SCAD.