Each imaging modality offers unique diagnostic strengths. While invasive coronary angiography remains first-line, multi-detector computed tomography (MDCT) shows promise as a non-invasive alternative with high sensitivity and specificity; cardiac magnetic resonance (CMR) provides valuable information about myocardial injury, while optical coherence tomography (OCT) and intravascular ultrasound (IVUS) offer detailed vessel wall characterization, concluded a new systematic review.
The findings are published in American Heart Journal, in December 2025.
The findings highlight that a multimodality imaging approach optimizes diagnosis, guides management, and assesses prognosis in spontaneous coronary artery dissection (SCAD).
A Complex Condition Requiring Precision Diagnosis
Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of coronary artery obstruction caused by a spontaneous tear or bleeding within the vessel wall. It increasingly causes acute coronary syndrome, especially in young women without traditional cardiovascular risk factors. Early and accurate diagnosis is essential because SCAD management differs significantly from conventional atherosclerotic acute coronary syndrome.
This diagnostic challenge has intensified interest in advanced imaging techniques capable of characterizing vessel wall abnormalities, identifying intramural hematomas, and assessing myocardial injury. The new systematic review provides a detailed overview of how invasive and non-invasive modalities contribute differently to SCAD diagnosis and follow-up.
Study Overview
Researchers followed PRISMA-DTA guidelines to conduct a structured search across MEDLINE, Embase, the Cochrane Library, and Web of Science. Independent reviewers screened eligible studies, extracted data, and assessed diagnostic accuracy using the QUADAS-2 tool.
Studies were included if they evaluated one or more imaging modalities used in SCAD: invasive coronary angiography (ICA), optical coherence tomography (OCT), intravascular ultrasound (IVUS), multidetector computed tomography (MDCT0), and cardiac magnetic resonance (CMR). This comprehensive approach allowed comparison across modalities and assessed their respective strengths and limitations.
Key Findings from the Study
- The review highlighted that MDCT demonstrated higher diagnostic accuracy for SCAD detection than traditional coronary angiography, with a sensitivity of 98.6% compared to 77.8% for angiography and a specificity of 89.7% compared to 79.4%.
- MDCT also reliably identified wall abnormalities such as the characteristic “sleeve-like” thickening seen in over 70% of cases, as well as plaque-like appearances, visible intimal flaps, and total occlusions.
- OCT and IVUS, considered reference standards for vessel wall imaging, consistently identified intramural hematoma as the predominant pathological feature.
- CMR proved essential for assessing myocardial damage. It detected delayed enhancement in 83% of patients, indicating infarction, and identified microvascular obstruction—an important prognostic marker—in 44% of cases.
Despite the differences among modalities, MDCT and coronary angiography showed excellent correlation in stenosis severity grading. In acute SCAD presentations, CCTA successfully identified 78 percent of culprit lesions, suggesting its growing utility in emergency evaluation.
Clinical Importance: Multimodal Imaging Strategy Beneficial for Optimal SCAD Care
For clinicians managing suspected SCAD, this review reinforces the need to move beyond conventional angiography alone. Although angiography remains the first-line diagnostic tool in acute settings due to its availability and speed, it can miss subtle vessel wall abnormalities or misinterpret SCAD as atherosclerosis.
A multimodality imaging pathway enables cardiologists to tailor diagnostic and therapeutic approaches to each patient’s presentation, improving accuracy, safety, and outcomes. As awareness of SCAD continues to rise, integrating these imaging tools into clinical protocols may help reduce misdiagnosis and facilitate effective long-term management.
Reference: Essien E, Nwaezeapu K, Agyekum A, Ajenaghughrure G, Owusu-Achiaw J, Bediako EM. Diagnostic Approaches for Spontaneous Coronary Artery Dissection: A Systematic Review of Multimodality Imaging. American Heart Journal. 2025 Dec 1;290:7.
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