{
  "abstract": "Background Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of acute coronary syndrome, predominantly affecting younger patients without conventional cardiovascular risk factors. Although invasive coronary angiography (ICA) remains the diagnostic gold standard, most SCAD cases present as NSTEMI, for which conservative management is preferred to minimize iatrogenic harm. While intravascular imaging enhances diagnostic accuracy, CT coronary angiography (CTCA) offers a non invasive alternative. We propose CTCA as a first-line diagnostic modality in suspected SCAD to reduce procedural risk while preserving diagnostic confidence.Methods We retrospectively analyzed 27 consecutive patients presenting with suspected or confirmed SCAD. Patients underwent CTCA, ICA, or both. High-risk features included female sex, younger age, postpartum status, and connective tissue disorders. Clinical outcomes and management strategies were assessed (figures 1–4).Results The mean age was 46 years; 20 patients were female. CTCA was the initial imaging modality in 22 patients, while 5 underwent ICA first. Among those imaged initially with CTCA, 17(77%) were managed conservatively. Five patients proceeded to ICA – one had balloon angioplasty, one required stenting and one required coronary artery bypass grafting (CABG). Two patients had iatrogenic coronary dissection, resulting in one emergency CABG and one death. Of the patients undergoing ICA as first-line investigation, only one required intervention; the remainder were treated conservatively.Conclusion On this observational study, CTCA has been seen to help safely restructure the diagnostic pathway in patients with suspected SCAD presenting with NSTEMI, acting as a non invasive gatekeeper to ICA and reducing procedural risk while supporting appropriate patient selection for invasive management. A 46 year old woman presents with chest pain and elevated troponin. She has no conventional cardiovascular risk factors. ECG shows NSTEMI. SCAD is suspected based on clinical features. You are considering the safest initial imaging strategy. Which of the following is the most appropriate first line diagnostic modality in suspected SCAD presenting as NSTEMI?A. Invasive coronary angiography (ICA)B. CT coronary angiography (CTCA)C. Intravascular ultrasound (IVUS)D. Optical coherence tomography (OCT)Abstract 31 Figure 435-year-old female patient with no risk factors for coronary artery disease presented with acute onset chest pain and transient lateral wall STEMI. CT Coronary Angiography (A and B) was performed which showed smooth narrowing of proximal segment of RCA with adjacent fat stranding (red arrowheads) suggestive of spontaneous dissection. Rest of the coronaries were normal. Catheter angiography was not performed and patient was managed conservatively. Follow up CT coronary angiography (C and D) showed near-complete healing and normal caliber of the proximal segment of RCA (green arrowheads)Abstract 31 Figure 339-year-old female patient with hypertension and high BMI presenting with acute coronary syndrome. CT Coronary Angiography (A and B) was performed which showed smooth narrowing of ostium and proximal segment of LAD (red arrowheads) suggestive of spontaneous dissection. Rest of the coronaries were normal. Catheter angiography was deferred and patient managed conservatively. Follow up CT coronary angiography (C and D) showed complete healing and normal caliber of the ostium and proximal segment of LAD (white arrowheads)Abstract 31 Figure 255 year old female with hypertension, presenting with acute onset chest pain and elevated troponins. CT Coronary Angiography (A) was performed which showed severe circumferential ostial narrowing of LAD (red arrowheads). Rest of the coronaries were normal. Catheter angiography (B) was performed with a plan to stent / dilate the stenosis. Since a guide-wire could not be passed across the stenosis (red arrowheads), patient was shifted for an emergency coronary bypass surgeryAbstract 31 Figure 156 year old female patient with presenting with acute chest pain and elevated troponins and STEMI (ST Elevation Myocardial Infarction) in anterior leads on ECG. A) Catheter angiography showed long segment smooth segment narrowing in mid-LAD (red arrowheads). B) and C) CT Coronary Angiography confirming the finding (red arrowheads). Additionally, no atherosclerotic disease is seen in the coronary arteries. Diagnosis of SCAD was made and managed conservatively. D) and E) CT Coronary Angiography after 3 months showed improved caliber in mid-LAD (green arrowheads)E. Stress cardiac MRI",
  "authors": [
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Hariprasad Sudarsan"
    },
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Afshin Khalatbari"
    },
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Periaswamy Velavan"
    },
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Marousa Ntouskou"
    },
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Lucy Cosbey"
    },
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Enass Mohammed Al-Hadidi"
    },
    {
      "affiliations": [
        "Liverpool Heart and Chest Hospital"
      ],
      "name": "Ahmed Kharabish"
    }
  ],
  "title": "31 Shifting the diagnostic paradigm: CT coronary angiography as first-line imaging in suspected spontaneous coronary artery dissection",
  "uid": "ac0188c8-d3a4-568c-b665-29c9071633c4"
}