Letter to the Editor
Reply to Letter to the Editor “Focus on spontaneous coronary artery dissection: Where are we now?”
Resposta à Carta ao Editor «Foco na disseção espontânea da artéria coronária: Onde estamos agora?»
Glória Abreu
Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "953" "paginaFinal" => "955" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Foco na disseção espontânea da artéria coronária: Onde estamos agora?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2589 "Ancho" => 3000 "Tamanyo" => 604470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart for the diagnosis and management of spontaneous coronary artery dissection.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Dario Buccheri" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Dario" "apellidos" => "Buccheri" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255118304955?idApp=UINPBA00004E" "url" => "/08702551/0000003700000011/v4_201911280953/S0870255118304955/v4_201911280953/en/main.assets" ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Reply to Letter to the Editor “Focus on spontaneous coronary artery dissection: Where are we now?”" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "957" "paginaFinal" => "958" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Glória Abreu" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Glória" "apellidos" => "Abreu" "email" => array:1 [ 0 => "gloriappabreu@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Braga, Braga, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Resposta à Carta ao Editor «Foco na disseção espontânea da artéria coronária: Onde estamos agora?»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We would like to thank Dario Buccheri for the interest shown in our article “Spontaneous coronary artery dissection: a single-center case series and literature review”.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We reported an interesting case series of spontaneous coronary artery dissection (SCAD) from our center, in which we presented the prevalence of SCAD in our cohort, its form of presentation, patient characteristics, how we managed the condition and its prognosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As the author pointed out, SCAD remains an underdiagnosed entity.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Therefore, it is crucial to have a high level of clinical suspicion, recognize some particular features characteristic of this entity, be familiar with all angiographic patterns and systematically use intracoronary imaging.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We analyzed with great interest the scoring system proposed and tested by Buccheri et al.,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a> which scores clinical and angiographic variables that raise the suspicion of SCAD and favors the use of optical coherence tomography or intravascular ultrasound to confirm the diagnosis. We think that it could be a useful and practical tool for diagnosis, although it still needs statistical validation in a larger cohort. Although invasive treatment is suggested in the score and in the letter, this kind of strategy is based on case reports and experience in short case series.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,6</span></a> Percutaneous treatment of SCAD may carry non-negligible risks, such as secondary iatrogenic dissection, guidewire passage into the false lumen, proximal or distal false lumen propagation during stent deployment, persistent distal dissection, major side branch occlusion or flow limitation, and subacute or late stent malapposition due to intramural hematoma reabsorption.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7,8</span></a> Indeed, technical failure of percutaneous coronary intervention may occur in up to half of patients with SCAD.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Dr. Buccheri proposed that in this setting, bioresorbable vascular scaffolds (BVS) might be an interesting therapeutic tool because they allow for SCAD sealing and healing, theoretically with subsequent restoration of the morphological and functional characteristics of the coronary segment treated. This option could be of great importance in cases of long SCAD requiring multiple overlapping permanent stents, which are associated with a high rate of adverse events at follow-up. However, compared with newer drug-eluting stents, BVS are associated with higher risk of device thrombosis and target lesion failure,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> and thus they would probably require longer clinical follow-up and intracoronary imaging control to assess vascular repair and device failure.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In fact, the optimal treatment strategy remains controversial and undetermined, as no randomized trials comparing conservative with revascularization strategies have been carried out. Nevertheless, there is good evidence that the majority of SCAD will first stabilize and then heal completely over time, if managed conservatively.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9,11–13</span></a> It is recognized that revascularization in SCAD is challenging, because of the presence of an underlying disrupted and friable vessel wall, not infrequently leading to a suboptimal outcome.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9,12,14</span></a> In stable patients, i.e. those in whom revascularization is not required, a conservative strategy is generally accepted.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15,16</span></a> Given the current concern about this condition, the European Society of Cardiology has created a SCAD registry, which we expect will help us to improve our knowledge about this subject.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous coronary artery dissection: a single-center case series and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 3 | 9 |
| 2024 Outubro | 34 | 21 | 55 |
| 2024 Setembro | 44 | 27 | 71 |
| 2024 Agosto | 31 | 25 | 56 |
| 2024 Julho | 32 | 22 | 54 |
| 2024 Junho | 25 | 23 | 48 |
| 2024 Maio | 25 | 23 | 48 |
| 2024 Abril | 31 | 23 | 54 |
| 2024 Maro | 24 | 19 | 43 |
| 2024 Fevereiro | 21 | 18 | 39 |
| 2024 Janeiro | 19 | 30 | 49 |
| 2023 Dezembro | 13 | 22 | 35 |
| 2023 Novembro | 32 | 24 | 56 |
| 2023 Outubro | 13 | 13 | 26 |
| 2023 Setembro | 15 | 23 | 38 |
| 2023 Agosto | 26 | 14 | 40 |
| 2023 Julho | 19 | 11 | 30 |
| 2023 Junho | 17 | 13 | 30 |
| 2023 Maio | 37 | 21 | 58 |
| 2023 Abril | 19 | 2 | 21 |
| 2023 Maro | 23 | 18 | 41 |
| 2023 Fevereiro | 32 | 21 | 53 |
| 2023 Janeiro | 14 | 5 | 19 |
| 2022 Dezembro | 31 | 21 | 52 |
| 2022 Novembro | 28 | 29 | 57 |
| 2022 Outubro | 35 | 22 | 57 |
| 2022 Setembro | 26 | 40 | 66 |
| 2022 Agosto | 26 | 25 | 51 |
| 2022 Julho | 17 | 40 | 57 |
| 2022 Junho | 26 | 23 | 49 |
| 2022 Maio | 16 | 31 | 47 |
| 2022 Abril | 28 | 34 | 62 |
| 2022 Maro | 25 | 40 | 65 |
| 2022 Fevereiro | 17 | 22 | 39 |
| 2022 Janeiro | 20 | 25 | 45 |
| 2021 Dezembro | 21 | 24 | 45 |
| 2021 Novembro | 19 | 35 | 54 |
| 2021 Outubro | 32 | 41 | 73 |
| 2021 Setembro | 17 | 27 | 44 |
| 2021 Agosto | 22 | 32 | 54 |
| 2021 Julho | 7 | 14 | 21 |
| 2021 Junho | 17 | 22 | 39 |
| 2021 Maio | 26 | 24 | 50 |
| 2021 Abril | 28 | 19 | 47 |
| 2021 Maro | 38 | 16 | 54 |
| 2021 Fevereiro | 35 | 13 | 48 |
| 2021 Janeiro | 16 | 10 | 26 |
| 2020 Dezembro | 24 | 12 | 36 |
| 2020 Novembro | 17 | 12 | 29 |
| 2020 Outubro | 7 | 9 | 16 |
| 2020 Setembro | 25 | 10 | 35 |
| 2020 Agosto | 13 | 9 | 22 |
| 2020 Julho | 10 | 8 | 18 |
| 2020 Junho | 13 | 11 | 24 |
| 2020 Maio | 9 | 5 | 14 |
| 2020 Abril | 18 | 18 | 36 |
| 2020 Maro | 40 | 6 | 46 |
| 2020 Fevereiro | 72 | 17 | 89 |
| 2020 Janeiro | 52 | 4 | 56 |
| 2019 Dezembro | 21 | 5 | 26 |
| 2019 Novembro | 13 | 4 | 17 |
| 2019 Outubro | 17 | 7 | 24 |
| 2019 Setembro | 52 | 7 | 59 |
| 2019 Agosto | 29 | 2 | 31 |
| 2019 Julho | 38 | 9 | 47 |
| 2019 Junho | 22 | 10 | 32 |
| 2019 Maio | 17 | 3 | 20 |
| 2019 Abril | 16 | 12 | 28 |
| 2019 Maro | 11 | 9 | 20 |
| 2019 Fevereiro | 14 | 16 | 30 |
| 2019 Janeiro | 30 | 11 | 41 |
| 2018 Dezembro | 34 | 32 | 66 |
| 2018 Novembro | 12 | 22 | 34 |
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