Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a relatively rare and unexplored type of coronary disease. Although atherosclerosis, hormonal changes during pregnancy and connective tissue disorders might represent a sufficiently convincing explanation for some patients with SCAD, the many remaining cases display only a weak relationship with these causes. While on one side the clinical heterogeneity of SCAD masks a full understanding of their underlying pathophysiologic process, on the other side paucity of data and misleading presentations hamper the quick diagnosis and optimal management of this condition. A definite diagnosis of SCAD can be significantly facilitated by endovascular imaging techniques. In fact, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) overcome the limitations of coronary angiography providing detailed endovascular morphologic information. In contrast, optimal treatment strategies for SCAD still represent a burning controversial question. Herein, we review the published data examining possible causes and investigating the best therapy for SCAD in different clinical scenarios.     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) should be considered as a cause of the acute coronary syndrome in young patients with few apparent risk factors for coronary artery disease, in females in the peripartum period, and in patients who are at a higher risk for this condition. SCAD can also present as sudden death and cardiogenic shock. Several mechanisms have been described in the pathophysiology of this condition. Urgent coronary angiography is indicated if SCAD is suspected. Percutaneous coronary artery stenting and coronary artery bypass grafting are the main treatment strategies.     

Spontaneous coronary artery dissection with multiple coronary artery aneurysms in a patient with diabetic ketoacidosis

Spontaneous coronary artery dissection (SCAD) is a very rare and commonly fatal condition that typically presents with signs and symptoms of an acute myocardial infarction and cardiogenic shock. We herein present a case of a 54-year-old woman who was diagnosed with diabetic ketoacidosis (DKA) as the first manifestation of her underlying diabetes mellitus, while being hospitalized for treatment, she was found to have a non ST-elevation myocardial infarction (NSTEMI), an urgent cardiac catheterization revealed a complete dissection of the right coronary artery (RCA) with an intraluminal thrombus formation and multiple aneurismal dilatations in the left anterior descending (LAD) and left circumflex (LC) arteries. The patient underwent coronary artery bypass grafting with a favorable outcome.     

Spontaneous left main coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a very rare clinical condition. Physiopathology of SCAD is still mostly unclear. Clinical presentation of SCAD ranges from atypical symptoms to sudden cardiac death. The diagnosis of dissection is generally made by using conventional coronary angiography. Invasive or conservative treatment is reasonable.     

Spontaneous coronary artery dissection - a mimic

Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening condition if it goes unrecognized. Symptoms can range from chest pain to sudden cardiac death. We present a case of 33 year-old female marathon runner who presented to emergency department (ED) complaining of sudden onset of non-positional, constant, pleuritic chest discomfort. She was eventually found to have spontaneous dissection of coronary artery. The mimicking nature of SCAD is presented in this article. We conclude that spontaneous coronary dissection, although still challenging due to its mimicking nature, should be considered in the differential diagnosis of chest pain and associated myocardial injury.     

Spontaneous coronary artery dissection in a professional body builder

A 23-year-old male, a professional body builder, developed squeezing retrosternal chest pain following weight lifting. On examination, heart rate was 42 bpm and he had blood pressure of 70/50 mm Hg. An electrocardiogram was taken and showed inferior and right ventricular ST elevation myocardial infarction. Therefore, emergency coronary angiography was done and showed normal left coronaries. Right coronary artery angiogram revealed a dissection in the mid-part of the right coronary artery which was extended to the right ventricular branch.     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischemia with complex pathophysiology. This paper reviews the major diagnostic and therapeutic issues of this rare but important disease. The diagnosis of SCAD should be strongly considered in any patient who presents with symptoms suggestive of acute myocardial ischemia, particularly in young subjects without traditional risk factors for coronary artery disease (especially in young women during the peripartum period or in association with oral contraceptive use). Urgent coronary angiography is indicated to establish the diagnosis and to determine the appropriate therapeutic approach. The decision to pursue medical management, percutaneous coronary intervention, or surgical revascularization is based primarily on the clinical presentation, extent of dissection, and amount of ischemic myocardium at risk.     

Spontaneous coronary artery dissection: Case series and review of literature

AimSpontaneous coronary artery dissection (SCAD) is a less recognized cause of ST elevation myocardial infarction (STEMI) in clinical practice. The aim of this communication is to describe a case series in South Asian population and highlight on the long-term clinical outcomes on conservative management.MethodsA retrospective analysis of data of five patients (6 instances) of SCAD managed in a tertiary care center during January 1994 to June 2015 was done. Clinical, angiographic, therapeutic, and follow-up data till end of June 2015 are analyzed.ResultsAll patients were young (mean – 33 years) and predominantly male. Etiology of SCAD was diverse and included peripartum state, vigorous activity and atherosclerosis. Left anterior descending (LAD) coronary artery was predominantly involved and the majority had angiographic type 1 SCAD. Medical treatment provides excellent long-term benefits. Coronary stenting provided symptomatic benefit in a patient with favorable anatomy.ConclusionsClinical recognition of SCAD is difficult. It should be suspected in peripartum state, young females and in presence of other precipitating factors. Coronary angiography is essential for establishing the diagnosis. Medical treatment provides favorable long-term survival.Implications and practiceThe awareness of SCAD is important for all clinicians involved in STEMI care. A prompt suspicion can avoid administration of thrombolytic therapy. Early coronary angiography will provide an accurate diagnosis and help in deciding appropriate therapy. Percutaneous intervention can be challenging.     

Spontaneous coronary artery dissection and associated CT coronary angiographic findings: a case report and review

We report a case of an acute coronary syndrome in a 21-year-old male with invasive coronary angiography and computed tomography (CT) coronary angiography showing a spontaneous dissection of the left anterior descending artery. To our knowledge the CT coronary angiographic appearance of spontaneous coronary artery dissection has been reported only once before. We describe the role CT coronary angiography may have in the evaluation of coronary dissection as well as potential treatment options.     

Spontaneous coronary artery dissection: A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic, non-traumatic separation of the coronary artery wall. The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors. SCAD is frequently linked with predisposing factors, such as postpartum, fibromuscular dysplasia or other vasculopathies, connective tissue disease and hormonal therapy, and it is often triggered by intense physical or emotional stress, sympathomimetic drugs, childbirth and activities increasing shear stress of the coronary artery walls. Patients with SCAD usually present at the emergency department with chest discomfort, chest pain, and rapid heartbeat or fluttery. During the last decades, the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis. However, modern imaging techniques such as optical coherence tomography, intravascular ultrasound, coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease. Treatment of SCAD remains controversial, especially during the last years, where invasive techniques are being used more often and in more emergent cardiac syndromes. Although conservative treatment combining aspirin and beta-blocker remains the recommended strategy in most cases, revascularization could also be suggested as a method of treatment in specific indications, but with a higher risk of complications. The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients. Follow-up should be performed on a regular basis.     

Spontaneous coronary artery dissection in young women

Spontaneous dissection of the coronary arteries is quite rare. It is usually a catastrophic event with fatal outcome. We report two interesting cases of spontaneous dissection whose presentations exemplify the variable course the disorder may take. The first is the only report to our knowledge associated with aerobic exercise; the second is the only reported attempt at treatment with intracoronary thrombolysis. © 1996 Wiley-Liss, Inc.     

Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review

Spontaneous coronary artery dissection is a rare cause of myocardial ischemia and sudden death. Coronary aneurysms and pseudoaneurysms, which may occur after percutaneous coronary interventions, rarely occur spontaneously. We review the pertinent medical literature and describe the intravascular findings of spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms.     

Spontaneous coronary artery dissection in mitral stenosis

Spontaneous coronary artery dissection is a rare disease thatoccurs most commonly in young people, especially in peripartumor postpartum women. It has rarely been diagnosed during lifeand has never before been observed associated with any othernon-ischaemic heart disease. We report a case associated withmitral stenosis, in which successful valvular and coronary surgerywere carried out. We speculate whether rheumatic coronary arteritiswas a cause of the dissection.     

原发性冠状动脉夹层的造影特点及介入治疗

目的　了解原发性冠状动脉夹层 (SCAD)的发生情况及介入治疗的效果。方法　分析 22 16例冠状动脉造影以发现SCAD ;对适合经皮冠状动脉介入治疗术 (PCI)的SCAD患者行支架置入术 ,手术前后及手术中按要求使用阿司匹林、氯吡格雷、肝素或低分子肝素等药。结果　发现SCAD共 2 6例 ,男 19例 ,女 7例 ,平均年龄 (6 0 9± 11 6 )岁 (34～ 75岁 ) ,检出率为 1 17%。其中急性心肌梗死 15例 ,不稳定型心绞痛 11例。 2 6例患者共 2 8支血管发生SCAD。其中冠状动脉左主干 1例 ,左前降支 9例 ,回旋支 4例 ,右冠状动脉 14例。对适合PCI术的 18例患者 19支血管撕裂处行支架置入术。其中 14例 15处行经皮腔内冠状动脉成形术 (PTCA) 支架置入术 ,4例行直接支架置入术。撕裂处共置入支架 2 3枚。支架置入术后 ,1例冠状动脉原发性撕裂处残余狭窄小于 30 % ,另 1例残余狭窄小于 10 % ,其余 16例均无残余狭窄。经介入治疗后患者的临床症状均明显缓解。结论　SCAD并非罕见 ,存在冠状动脉粥样斑块者是SCAD相对高发的人群。支架置入术是治疗SCAD较为理想的方法。     

Spontaneous coronary artery dissection (SCAD): The underdiagnosed cardiac condition that plagues women

Coronary heart disease (CHD) continues to be understudied, underdiagnosed, and undertreated in women. Gender and age bias complicate the evaluation of women with acute coronary syndrome (ACS). As a result, conditions like spontaneous coronary artery dissection (SCAD) are often missed. SCAD is an infrequent yet important cause of myocardial infarction (MI) with a predilection for young to middle aged women. The condition is thought to be under-reported, likely a result of both low index of suspicion as well as an unfamiliarity with SCAD’s angiographic variants. Recently, the European Society of Cardiology (ESC) detailed an assessment pathway for patients with myocardial infarction with non-obstructive coronary arteries (MINOCA), a subset of which includes patients with SCAD. The pathway highlights the role of cardiac magnetic resonance (CMR) in addition to intracoronary imaging for increased diagnostic yield. Early and proper diagnosis is crucial in SCAD given the potential for sudden cardiac death, as well as the increased risk for future cardiac events including recurrent dissection. In addition, SCAD has frequently been associated with underlying connective tissue disease and/or arteriopathy, most commonly fibromuscular dysplasia (FMD), which requires careful screening. The lack of consensus on investigation or treatment highlights the need for increased awareness and further research to better understand this challenging entity.     

冠状动脉自发性夹层的临床特点与治疗策略

目的回顾分析冠状动脉自发性夹层（SCAD）患者的临床资料,探讨治疗策略。方法回顾分析2010年7月至2013年3月单中心冠状动脉造影患者4517例,检出SCAD13例,借用冠状动脉夹层分型系统对病变进行分类,分析不同类型SCAD的发生率、影像特点及随访临床事件。结果13例SCAD患者中,2例（2／13,15．4％）发生2处夹层,共存在15处夹层。12例（92．3％）发生临床事件,包括心肌梗死10例（76．9％）与心绞痛2例（15．4％）。发生于右冠状动脉夹层9处（9／15,60％）,前降支6处（6／15,40％）,左回旋支未见夹层。A型病变1处（6．7％）,B型2处（13．3％）,D型8处（53．3％）,E型2处（13．3％）,F型1处（6．7％）,壁间血肿1处（6．7％）。4例5处保守治疗,9例10处病变给予经皮冠状动脉介入治疗（PCI）,9处病变PCI治疗成功,1处未成功改为冠状动脉旁路移植术。1例D型夹层患者药物治疗6个月后复查冠状动脉造影,夹层无明显变化,无心绞痛发作;l例D型夹层患者药物治疗3个月,仍有心绞痛,给予PCI治疗;1例A型夹层患者PCI后12个月复查冠状动脉造影未见夹层复发,无再狭窄。其余患者电话随访6～12个月无临床事件。结论SCAD可以按照NHLB1分型。A、B、E型及壁间血肿采取PCI治疗相对容易。D型夹层占比例最高。D、F型治疗难度最大。关键在于早期确诊。可以根据病变的类型、长度,选择性地采取PCI治疗,保守治疗是否可以自愈仍需长期随访。     

Spontaneous coronary artery dissection and takotsubo syndrome: The chicken or the egg causality dilemma

Acute coronary syndrome (ACS) including spontaneous coronary artery dissection (SCAD) has been reported to trigger its own clinical twin takotsubo syndrome (TS). The pathogenetic association between SCAD and TS remains to be elucidated. The two diseases afflict predominantly women and both conditions may be triggered by an emotional stress factor and an unusual extreme physical exercise. Herein, we describe a case of 54‐year‐old woman presenting with ACS caused by an obtuso‐marginal SCAD. Concurrently, the patient had typical clinical features and course of mid‐apical pattern of TS. The causal link between the two conditions is discussed. © 2017 Wiley Periodicals, Inc.     

Spontaneous coronary artery dissection with pseudoaneurysm formation diagnosed by intravascular ultrasound: a case report

Spontaneous coronary artery dissection is a rare cause of myocardial ischemia. Coronary artery pseudoaneurysm may occur after percutaneous coronary interventions and rarely spontaneously. We present a patient who had spontaneous coronary artery dissection with formation of a pseudoaneurysm diagnosed by intravascular ultrasound.