Letter to the Editor
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Respuesta
Pedro Cepas-Guillén
, Eduardo Flores-Umanzor, Mónica Masotti
Corresponding author
Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Kanga, H. Zhanga.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We would like to thank G. Kanga and H. Zhanga for their interest and pertinent comments about our recent review of spontaneous coronary artery dissection (SCAD).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> As the authors claim in their Letter to the Editor, SCAD is an often-misdiagnosed non-atherosclerotic mechanism of acute coronary syndrome which mainly affect female patients with a mean age of 40–50 years (almost >80% in most of cohorts). The condition causes 1%–4% of all cases of acute coronary syndrome, reaching as much as 35% of all myocardial infarctions in women younger than 50 years. Many different factors have been related to the development of SCAD. One of the most studied and prevalent predisposing factors is the presence of fibromuscular dysplasia, a non-inflammatory arteriopathy, that is found in almost 40% of patients with SCAD. Previous history of hypertension, migraine headache and pregnancy or postpartum status are other relevant associations with SCAD. The presence of these latter, pregnancy or postpartum status, might suggest that sex hormones, mainly estrogen and progesterone, may play an important role in its pathophysiology as G. Kanga and H. Zhanga detail in their article. It is widely known that estrogen and progesterone produce structural and functional changes in the coronary arteries. The action of estrogen is more studied than progesterone which need additional study. Estrogen acts by different pathways in coronary arteries: can activate endothelial nitric oxide synthase in the vascular endothelium (producing nitric oxide and, ultimately, coronary vasodilation), decrease oxidative stress by reducing mitochondrial-reactive oxygen species and promote angiogenesis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this direction, most postpartum SCAD occurs shortly after pregnancy, when estrogen and progesterone levels fall down, suggesting that the relative changes in circulating hormones may contribute to the underlying mechanism of SCAD. Nonetheless, the potential harms of exogenous hormones among women with a history of SCAD are unknown. Both, the American Heart Association and European Society of Cardiology, in their Scientific Statement and Position Paper on SCAD, respectively, admit that the connection between other potential hormone-mediated SCAD triggers, such as the perimenopausal state, use of oral contraceptives, postmenopausal hormone therapy or infertility treatments, although have been reported, have less supportive data (unlike hormonal triggers related to pregnancy).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> Because these associations are based on anecdotal case reports, causality is harder to determine. If we look the presence of active hormonal therapy among clinical characteristics in female with SCAD, we observe difference results. In the largest cohort study carried out, which include 750 patients from Canadian SCAD cohort study, 10% of them have active hormonal therapy as a potential predisposing condition.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In other cohorts, the association is less frequent, and in most cases, it is not even collected. Thus, the biggest challenge for confirming this correlation is that the baseline prevalence of active hormonal therapy is, in most of the cases, either common in the general population or unknown. Only future larger scale prospective and epidemiological studies will help to improve our understanding about predisposing conditions and precipitating stressors in SCAD patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authorship</span><p id="par0020" class="elsevierStylePara elsevierViewall">All authors had access to the data and played a role in writing this manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authorship" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous coronary artery dissection: not so infrequent to be ignored" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.L. Cepas-Guillén" 1 => "E. Flores-Umanzor" 2 => "M. Sabate" 3 => "M. Masotti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medcli.2019.02.022" "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2019" "volumen" => "153" "paginaInicial" => "245" "paginaFinal" => "249" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The evidence on estrogen, progesterone, and spontaneous coronary artery dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.S. Tweet" 1 => "V.M. Miller" 2 => "S.N. Hayes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamacardio.2019.0774" "Revista" => array:6 [ "tituloSerie" => "JAMA Cardiol" "fecha" => "2019" "volumen" => "4" "paginaInicial" => "403" "paginaFinal" => "404" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30969320" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Adlam" 1 => "F. Alfonso" 2 => "A. Maas" 3 => "C. Vrints" 4 => "A. al-Hussaini" 5 => "H. Bueno" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehy080" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2018" "volumen" => "39" "paginaInicial" => "3353" "paginaFinal" => "3368" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29481627" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous coronary artery dissection: current state of the science: a scientific statement from the American Heart Association" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.N. Hayes" 1 => "E.S.H. Kim" 2 => "J. Saw" 3 => "D. Adlam" 4 => "C. Arslanian-Engoren" 5 => "K.E. Economy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIR.0000000000000564" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2018" "volumen" => "137" "paginaInicial" => "e523" "paginaFinal" => "e557" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29472380" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Canadian spontaneous coronary artery dissection cohort study: in-hospital and 30-day outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Saw" 1 => "A. Starovoytov" 2 => "K. Humphries" 3 => "T. Sheth" 4 => "D. So" 5 => "K. 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