We appreciate the interest of Buccheri et al. in our report.1 After reading it carefully, we would like to comment on their considerations.
Spontaneous coronary artery dissection (SCAD), formerly considered rare, is now the most common cause of myocardial infarction associated with pregnancy and an important cause of acute coronary syndrome in women under the age of 50 years, in whom it can reach a prevalence of nearly 30%.2 However, it is difficult to diagnose unless there is a high level of suspicion, and interventional cardiologists are not familiar with the most common angiographic pattern of SCAD (type 2). This leads to erroneous diagnoses and the underdiagnosis of SCAD.
The advent of intracoronary imaging techniques (optical coherence tomography and intravascular ultrasound) has contributed to the optimization of the identification of this entity.3 These techniques are essential parts of the algorithms designed for the diagnosis and treatment of SCAD.4 The system proposed by Buccheri et al.5 is novel in that it scores clinical and angiographic variables that increase the suspicion of SCAD, an approach that favors the use of optical coherence tomography and/or intravascular ultrasound to confirm and treat it. We consider this to be a useful and practical diagnostic strategy that certainly would avoid many erroneous diagnoses. However, the treatment they propose is based on their own experience and a review of the literature; in contrast to atherosclerotic disease, there are no randomized controlled trials dealing with SCAD, and the conservative strategy proves to be valid for most stable patients. Therefore, while their generalized implementation is well-founded, at the present time, it is not a very likely prospect. Nevertheless, we agree that it can be a starting point from which, working together, we could establish the optimal management of SCAD and that this be reflected in our clinical practice guidelines.