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

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.     

A breastfeeding woman with spontaneous coronary artery dissection and possible takotsubo syndrome: A case report

Rationale:The relationship between spontaneous coronary artery dissection (SCAD) and takotsubo syndrome (TTS) remains unclear. Coexistence of SCAD and TTS has been reported in the literature. However, the relationship between these two diseases has not yet been elucidated.Patient concerns:A 36-year-old breastfeeding woman was brought to our hospital 52 days after cesarean section because of discomfort in her left arm and convulsions.Diagnoses:She was diagnosed of acute myocardial infarction (AMI). The convulsions were attributed to lethal arrhythmia.Interventions:An immediate coronary angiography revealed that her left anterior descending artery (LAD) was Type 2a SCAD, but with no flow limitation. In addition, a 12-lead electrocardiogram (ECG) revealed improvement in ST-elevation. We chose the conservative treatment according to the patient''s needs.Outcomes:Conservative treatment was unsuccessful. She developed another acute myocardial infarction requiring another percutaneous coronary intervention (PCI) during hospitalization. From the course of hospitalization, we suspected the coexistence of SCAD and TTS.Lessons:When we treat patients with SCAD, we should consider the possibility of coexistence of TTS and confirm left ventricular wall motion. Patients with SCAD may require invasive treatment, hence, should be monitored for a while. An urgent strategy for managing patients with SCAD who require PCI should be established.     

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: favorable outcome illustrated by angiographic data.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. It typically occurs in young women receiving oral contraceptive therapy or during the peripartum period. In the case presented here, spontaneous complete healing at angiography and the favorable outcome may support the role of conservative treatment in such patients.     

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.     

Case reports of coronary fibromuscular dysplasia and spontaneous coronary artery dissections

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome especially in women. The most common underlying predisposing cause of SCAD is fibromuscular dysplasia (FMD), a non‐inflammatory arteriopathy that results in weakening of the affected arteries, and can cause dissection or aneurysm. Coronary FMD (CFMD) was described as rare, and was shown to cause SCAD in histopathological case reports. Unfortunately, CFMD is challenging to diagnose on coronary angiography, as the findings can be similar to other causes of coronary artery disease. Therefore, we illustrate two case examples of CFMD on coronary angiography, and highlight findings on optical coherence tomography to aid diagnosis.     

Spontaneous coronary artery dissection in a young man with anterior myocardial infarction

A case of spontaneous coronary artery dissection in a young male with subsequent myocardial infarction is reported. In addition, distal vessel occlusion is noted, presumably from embolization of thrombotic material originating from the site of dissection. Postulated mechanisms of this uncommon cause of myocardial infarction and subsequent therapeutic options are reviewed.     

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 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 coronary artery dissection: A Western Denmark Heart Registry Study

Background : Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that associates with a high acute‐phase mortality rate, whereas long‐term outcome is less well described. Objective : To describe the incidence, predictors, and prognosis of SCAD. Design : Retrospective case‐identification study from the Western Denmark Heart Registry and the database of the Forensic Institute at Aarhus University from 1999 through 2007. Results : SCAD was documented in 22 of 32,869 (0.7‰) angiograms in the angiographic registry. The SCAD incidence among cases of ACS was 22 of 11,175 (2.0‰). None was seen in the forensic database. The mean age was 48.7 ± 8.9 years (range: 37–71 years). Females constituted 17 of 22 (77%) patients and all had undergone one or more pregnancies; two cases occurred in the postpartum period. The left descending artery (LAD) was the predominant site of entry. The age distribution, prevalence of the cardiovascular risk factors, presence of coronary atherosclerosis, and entry of the dissection were comparable among genders. Treatment was percutaneous coronary intervention in 13 of 22 (59%), coronary artery bypass operation in 2 of 22 (9%), and medical treatment in 7 of 22 (32%) patients. The mean follow‐up period was 3.6 ± 2.9 years. One patient suffered from recurrent SCAD; another patient died suddenly. The MACE‐ (cardiac death, nonfatal myocardial infarction, and new revascularization) free survival was 81% after 24 months. Conclusion : SCAD is a rare disease that mainly affects younger women. Compared with earlier reports, the prognosis seems to be improved by early diagnosis and interventional treatment. © 2009 Wiley‐Liss, 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.     

Invasive versus conservative management in spontaneous coronary artery dissection: A meta-analysis and meta-regression study

BackgroundData regarding the best treatment for spontaneous coronary artery dissection (SCAD) are limited. The aim of the present study was to compare the clinical outcomes of conservative versus invasive treatment in SCAD patients.MethodsWe systematically searched the literature for studies evaluating the comparative efficacy and safety of invasive revascularization versus medical therapy for the treatment of SCAD from 1990 to 2020. The study endpoints were all-cause death, cardiovascular death, myocardial infarction, heart failure, SCAD recurrence and target vessel revascularization (TVR) rates. Random effect meta-analysis was performed by comparing the clinical outcomes between the two groups. A univariate meta-regression analysis was also performed.ResultsTwenty-four observational studies with 1720 patients were included. After 28 ± 14 months, a conservative approach was associated with lower TVR rate compared with invasive treatment (OR = 0.50; 95%CI 0.28–0.90; P = 0.02). No statistical difference was found regarding all-cause death (OR = 0.81; 95%CI 0.31–2.08; P = 0.66), cardiovascular death (OR = 0.89; 95%CI 0.15–5.40; P = 0.89), myocardial infarction (OR = 0.95; 95%CI 0.50–1.81; P = 0.87), heart failure (OR 0.96; 95%CI 0.41–2.22; P = 0.92) and SCAD recurrence (OR = 0.94; 95%CI 0.52–1.72; P = 0.85). The meta-regression analysis suggested that male gender, diabetes mellitus, smoking habit, prior coronary artery disease, left main coronary artery involvement, lower ejection fraction and low TIMI flow at admission were related with high overall mortality, whereas SCAD recurrence was higher among patients with fibromuscular dysplasia.ConclusionsA conservative approach was associated with similar clinical outcomes and lower TVR rates compared with an invasive strategy in SCAD patients; future prospective studies are needed to confirm these results.     

自发性冠状动脉夹层并血栓形成致急性心肌梗死2例

急性心肌梗死(AMI)是心内科的常见急症,其病死率和致残率较高。自发性冠状动脉夹层(SCAD)可因假腔压迫及合并血栓形成导致冠状动脉闭塞,是AMI的罕见病因之一。本文报告2例SCAD并血栓形成致AMI,并行冠状     

Incidence and angiographic characteristics of patients With apical ballooning syndrome (takotsubo/stress cardiomyopathy) in the HORIZONS‐AMI trial

Objectives : To determine the incidence, clinical characteristics, and the coronary angiographic features of patients with apical ballooning syndrome (ABS) among those recruited into a large, prospective, international, multicenter trial. Background : ABS is an important entity in the differential diagnosis of ST‐elevation myocardial infarction (STEMI). Current data regarding ABS are limited to single center registries. Methods : Patients with ABS were identified, based on the Mayo Clinic diagnostic criteria, from those enrolled into the HORIZONS‐AMI trial. Quantitative angiography was performed by a core laboratory to identify the frequency and severity of coronary artery disease. Results : Among the 2,648 patients who had left ventriculography in addition to coronary angiography, 12 patients were identified with ABS. All patients were female and they were compared to the remaining 571 female patients with STEMI. Compared with patients with STEMI (97.9% of our cohort), patients with ABS (2.1%) had a lower prevalence (42% vs. 100%, P < 0.05) and severity (number of plaques measuring >30% diameter stenosis per patient: 0.58 ± 0.90 vs. 4.13 ± 2.68, P < 0.0001) of coronary artery disease. There were no in‐hospital deaths or major adverse cardiovascular events (MACE) in the ABS group vs. 2.1% and 3.7% respectively in the STEMI group, nor at 2‐year follow up (death: 0% vs. 5.5%, MACE: 0% vs. 19.4%), but these differences were not statistically significant. Conclusions : In HORIZONS‐AMI, ABS was identified exclusively in women (2.1% of female patients, 0.5% of all patients) and MACE were absent in this uncommon but important group of patients. Coronary artery disease was often present in patients with ABS, but its prevalence and severity was significantly less compared with STEMI patients. © 2011 Wiley Periodicals, Inc.     

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 multivessel coronary artery dissection: repeated presentation in a healthy postmenopausal woman.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction which is infrequently diagnosed antemortem. Most previously reported cases were found in women of whom a significant proportion presented during pregnancy or the postpartum period. We describe the first antemortem case of spontaneous coronary artery dissection, unrelated to pregnancy or the postpartum state, which ultimately resulted in diffuse involvement of both the left and right coronary arteries over a period of 4 months. Pathophysiology and case management of this disorder are discussed.     

Immunosuppressive therapy for peripartum-type spontaneous coronary artery dissection: Case report and review

Background: A 35-year-old postpartum woman presented with myocardial infarction (MI) due to spontaneous coronary artery dissection (SCAD). In addition to conventional medical therapy, she was treated with immunosuppressive agents (prednisone and cytoxan) because of five noncontiguous coronary dissections, surgical inoperability, and postinfarction angina. Repeat angiography 94 days later demonstrated angiographically normal vessels. Methods: A literature review of 42 additional cases of peripartum SCAD was performed, and the results were compared with this patient. Results: Mortality was 48.8% (21/43). Sudden cardiac death was the initial presentation in 27.9% (12/43) of cases. The left coronary artery was involved in 78.6% (44/56) of dissections with left main segment dissection in 10 cases. In women who survived > 24 h post infarction, recurrent MI, usually due to a second coronary dissection, occurred in 20.8% (5/24). Histopathologic studies have often shown periadventitial inflammation (80%, 16/20), in which eosinophils predominate (68.8%, 11/16), and may be linked to the medial degeneration often found in these cases. Conclusions: The common observation of eosinophilic periadventitial inflammation suggests a role in the pathophysiology of this rare, yet serious condition. Aggressive immunosuppressive therapy in this case of multivessel dissection resulted in spontaneous angiographic healing of all lesions.