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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

ranging from 0% to 26.9% at 1 year and estimated 5-year Kaplan-Meier rates up to 27%.1-3,5–9 Similar to incident SCAD, recurrent SCAD may be triggered by intense physical exertion or psychosocial distress. Recurrent SCAD may be more common among patients with highly tortuous coronary arteries, underlying fibromuscular dysplasia, history of migraine headaches, and hypertension.1,4,10,11 Pregnancy in women with previous SCAD was not associated with recurrent SCAD in multivariable modeling that controlled for age at first SCAD, year of first SCAD, and history of fibromuscular dysplasia.12

2 Multiple studies have reported a high prevalence

of extracoronary vascular abnormalities (eg, cerebral aneurysms, pseudoaneurysms) and concomitant fibromuscular dysplasia among patients with SCAD. The true prevalence of these disorders is unclear because reports are based on screening rates between 30% and 80%.1-4,7,10,13–15 Table 14 lists screening questions that may point toward an underlying vasculopathy and, together with a detailed vascular physical examination, may facilitate a patientclinician discussion about benefits and risks of imaging extracoronary vascular beds.16 Although some cerebral aneurysms detected by screening have been large enough to warrant intervention, no studies to date show that screening for underlying arteriopathies changes patient treatment or patient outcomes. 3.	 No randomized trials exist of pharmacological man-

agement after SCAD. Using multivariable modeling, a Canadian prospective follow-up study of 327 patients with SCAD found that use of beta blockade was associated with a 64% reduction in recurrent SCAD.1 Given the pathophysiology of SCAD, statin therapy is not indicated for SCAD but should be continued for patients who qualify for statin therapy based on global cardiovascular risk or inherited disorders like FH.17 Patients who received a stent during their acute hospitalization for SCAD should continue DAPT (see Section 4.3.1, “Antiplatelet Therapy and Oral Anticoagulants”) in the outpatient setting.17 Several prospective registries and a randomized trial are underway to improve understanding of the natural history of SCAD and potential treatments.23,24

6.1.2 Ischemia With Nonobstructive Coronary Arteries

Recommendation for INOCA Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

2a B-R 1 In symptomatic patients with nonobstructive

CAD, a strategy of stratified medical therapy* guided by invasive coronary physiologic testing can be useful for improving angina severity and QOL.1,2

*See recommendation-specific supportive text for details.

Table 14.  Screening Questions for SCAD-Associated Arteriopathies and Connective Tissue Disorders Personal history (Have you ever been diagnosed with or experienced any of the following?) Early-onset hypertension Stroke or transient ischemic attack Pulsatile tinnitus Migraine headaches Renal infarction Subarachnoid hemorrhage Aneurysm (aortic, peripheral, brain) Dissection (aortic, peripheral) Rupture of hollow organs (intestinal, bladder, uterine) Pneumothorax Tendon or muscle rupture Joint dislocation Talipes equinovarus (clubfoot) Umbilical or inguinal hernia Scoliosis or pectus deformity Pregnancy complications (cervical incompetence, hemorrhage, uterine prolapse, hypertension) Poor wound healing Ectopia lentis Myopia Detached retina, early glaucoma, or early cataracts Tall stature Abnormality of cardiac valve Systemic inflammatory disease Family history (Does anyone in your family have the following?) Dissection (coronary, aortic, peripheral) Inherited arteriopathy or connective tissue disorder (eg, vascular Ehlers-Danlos syndrome, Marfan syndrome, Loeys-Dietz syndrome) Early stroke, early myocardial infarction, sudden cardiac death Review of systems (Are you currently experiencing any of the following?) Headaches Pulsatile tinnitus Postprandial abdominal pain Flank pain Claudication Easy bruising Joint hypermobility or laxity SCAD indicates spontaneous coronary artery dissection. Reprinted with permission from Hayes SN, et al.16 Copyright 2007 American Heart Association, Inc.

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