Non-atherosclerotic causes of acute coronary syndromes

• Published in: Nature reviews cardiology 2020-04, Vol.17 (4), p.229-241
• Main Authors: Waterbury, Thomas M., Tarantini, Giuseppe, Vogel, Birgit, Mehran, Roxana, Gersh, Bernard J., Gulati, Rajiv
• Format: Article
• Language: English
• Subjects: 692/4019/592/75/2; 692/4019/592/75/593/1454; 692/4019/592/75/74; 692/420; 692/700/139; Acute coronary syndrome; Acute Coronary Syndrome - etiology; Acute coronary syndromes; Atherosclerosis; Cardiac Imaging; Cardiac Surgery; Cardiology; Cardiomyopathy; Cardiovascular disease; Care and treatment; Causes of; Coronary vessels; Diagnosis; Embolisms; Humans; Medicine; Medicine & Public Health; Review Article
• ISSN: 1759-5002; 1759-5010
• DOI: 10.1038/s41569-019-0273-3

Atherosclerosis and plaque disruption have a central pathological role in the majority of patients who present with an acute coronary syndrome (ACS), but non-atherosclerotic processes are also important contributors to a substantial number of ACS events and require different diagnostic and therapeutic strategies. In the absence of obstructive coronary artery disease, intravascular imaging techniques might be needed to delineate the underlying aetiology, together with a high index of suspicion for other important causes of ACS. In this Review, we discuss five non-atherosclerotic causes of ACS, including spontaneous coronary artery dissection, coronary artery embolism, vasospasm, myocardial bridging and stress-induced cardiomyopathy (Takotsubo syndrome). Important diagnostic findings, management strategies and prognostic data for these non-atherosclerotic mechanisms of ACS are reviewed. Non-atherosclerotic processes are important contributors to a substantial number of acute coronary syndrome events. In this Review, Gulati and colleagues discuss the diagnosis, management and prognosis of patients with spontaneous coronary artery dissection, coronary artery embolism, vasospasm, myocardial bridging or stress-induced cardiomyopathy (Takotsubo syndrome). Key points Non-atherosclerotic mechanisms contribute to a substantial number of acute coronary syndrome (ACS) events and require specific diagnostic and therapeutic strategies. Spontaneous coronary artery dissection is most common in younger women, and the preferred strategy of conservative management carries an important risk of early clinical deterioration. Coronary embolus can lead to ACS through direct, paradoxical or iatrogenic mechanisms. Coronary vasospasm can occur at the epicardial or microvascular level, and invasive coronary vasomotion testing can improve diagnosis. Myocardial bridging is often asymptomatic but can lead to ACS in an important subset of patients; invasive physiological testing might be necessary for diagnosis. Stress-induced cardiomyopathy (Takotsubo syndrome) is frequently associated with endothelial dysfunction and can acutely cause outflow tract obstruction.