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  • Review Article
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Non-atherosclerotic causes of acute coronary syndromes

Nature Reviews Cardiology volume 17, pages 229–241 (2020)Cite this article

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Abstract

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.

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.

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Fig. 1: Angiographic findings in spontaneous coronary artery dissection.
Fig. 2: Early evolution of spontaneous coronary artery dissection.
Fig. 3: Coronary embolus resulting in inferolateral ST-segment elevation myocardial infarction.
Fig. 4: Coronary vasospasm presenting as unstable angina.
Fig. 5: Myocardial bridging of the LAD.
Fig. 6: Ventriculography of stress-induced cardiomyopathy.

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Authors and Affiliations

  1. Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA

    Thomas M. Waterbury, Bernard J. Gersh & Rajiv Gulati

  2. Department of Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy

    Giuseppe Tarantini

  3. Cardiovascular Institute, Mount Sinai University, New York, NY, USA

    Birgit Vogel & Roxana Mehran

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T.M.W. researched the data for the article, and all the authors wrote the manuscript. T.M.W., B.J.G. and R.G. reviewed and edited the manuscript before submission.

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Waterbury, T.M., Tarantini, G., Vogel, B. et al. Non-atherosclerotic causes of acute coronary syndromes. Nat Rev Cardiol 17, 229–241 (2020). https://doi.org/10.1038/s41569-019-0273-3

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