Spontaneous coronary artery dissection

Pathophysiology of spontaneous coronary artery dissection: hematoma, not thrombus

Spontaneous coronary artery dissection (SCAD) accounts for 1.7%-4% of all acute coronary syndrome presentations, particularly among young women with an emerging awareness of its importance. The demarcation of acute SCAD from coronary atherothrombosis and the proper therapeutic approach still represents a major clinical challenge. Certain arteriopathies and triggers are related to SCAD, with high variability in their prevalence, and often, the cause remains unknown. The objective of this review is to provide contemporary knowledge of the pathophysiology of SCAD and possible therapeutic solutions.

Spontaneous Coronary Artery Dissection: A Literature Review

Spontaneous coronary artery dissection is a medical condition characterized by the rupture of the coronary artery wall, occurring without any external trauma. This ailment has been linked to various inflammatory, rheumatologic, and connective tissue disorders, as well as pregnancy-related changes. Despite being a less familiar cause of acute coronary syndrome, it has a considerable mortality rate, with incidence rates reaching up to 4%. This review will discuss the occurrence, pathophysiology, categorization, risk factors, diagnostic techniques, and treatment approaches related to spontaneous coronary artery dissection.

Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy

Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.

Desmin-related myopathy characterized by non-compaction cardiomyopathy, cardiac conduction defect, and coronary artery dissection

Desmin‐related myopathy (DRM) is a rare heritable cardiac and skeletal muscle disease caused by mutations in the desmin gene (DES). DRM is generally characterized by skeletal muscle weakness, conduction disturbance, and dilated cardiomyopathy. However, the clinical cardiac phenotypes of DRM are not yet fully understood. Herein, we report the first case of DRM with the de novo missense DES mutation, R454W, that is characterized by left ventricular non‐compaction cardiomyopathy, progressive cardiac conduction defect, spontaneous coronary artery dissection, and no skeletal muscle weakness. Our case findings suggest that clinicians should genetically test patients who have cardiomyopathy, progressive cardiac conduction defect, and coronary artery dissection, even if the patient has neither family history of DRM nor skeletal muscle symptoms.

An Unusual Presentation of Postpartum Spontaneous Coronary Artery Dissection

The postpartum population is one with a unique physiologic profile that predisposes these patients to rare and often life-threatening conditions. Herein, we discuss a case of a 37-year-old, multiparous female who presented to the emergency department with vague chest discomfort 14 days after delivering her sixth child via vaginal delivery. The patient was found to have elevated cardiac biomarkers and was ultimately diagnosed with pregnancy-related spontaneous coronary artery dissection (P-SCAD). This case report discusses the evaluation, pathophysiology, workup, and management of P-SCAD.

Spontaneous coronary artery dissection during cisplatin and capecitabine therapy

Introduction

Spontaneous coronary artery dissection is a rare cardiovascular disease that can cause acute myocardial infarction and sudden cardiac death. The mechanism of this pathology and the optimal treatment are not fully understood.

Presentation of case

An acute myocardial infarction developed while a fifty five years old woman with a rectal adenocarcinoma was receiving a cisplatin and capecitabine therapy. Coronary angiography demonstrated a multivessel occlusion of coronary arteries.

Discussion

The authors discuss several factors that may lead to the spontaneous coronary artery dissection including chemotherapy-induced vasospasm. Chemotherapy based on the cisplatin and capecitabine intake can cause a cardiotoxic effect.

Conclusion

Thus, spontaneous coronary artery dissection is a disease with an extremely complex etiololy, which does not have a special treatment guide. Management should be considered individually for each case.

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SCAD is a rare cardiovascular disease that can cause acute myocardial infarction and sudden cardiac death.

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Cisplatin and capecitabine therapy is a risk factor for SCAD.

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One of the most important side effects of chemotherapy is cardiotoxicity.

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Management should be considered individually for each case of SCAD.

Ischaemic heart disease and pregnancy: the tale of two stories

Ischaemic heart disease (IHD) is presumed to be rare in pregnancy. Based on that assumption, patients go undiagnosed or undertreated. IHD in pregnancy frequently occurs as a result of an unusual aetiology, therefore each patient needs to be managed individually since each may present differently. This may pose challenges to the consulting clinician. Pregnancy itself is a risk factor for cardiovascular disease, due to its associated hypercoagulable state. From current reports, the prevalence of IHD in females is increasing due to lifestyle changes, including cigarette smoking, diabetes and stress. In our modern societies, women delay childbearing until they are older, allowing time for risk factors to cluster. Although presumed to be rare in pregnant women, IHD is currently estimated to occur three to four times more often during pregnancy in middle– and high–income women, warranting an extensive review highlighting cases of IHD in pregnancy.

Cardiovascular Emergencies in Pregnancy

Heart disease in pregnancy may manifest as acute coronary syndromes, decompensated valvular disease, and acute heart failure. These disease processes may represent progression of preexisting disease versus newly developed disease resulting from the physiologic changes of pregnancy. Early recognition of clinical presentations, judicious use of diagnostic studies, and multidisciplinary management of patient and fetal considerations can lead to optimal outcomes in this unique patient subset.

Salvage myocardial revascularisation in spontaneous left main coronary artery dissection with cardiogenic shock – the role of mechanical circulatory support

Spontaneous left main coronary artery dissection is a rare cause of acute coronary events or sudden cardiac death, constituting less than 1% of all epicardial coronary artery dissections. It is often fatal and is mostly recognized at post-mortem examination in young victims of sudden death. More than 70% of the reported cases occurred in women, particularly during pregnancy and the peripartum period and those on oral contraceptives. The clinical presentation is highly variable and prognosis varies widely, depending predominantly on the speed of diagnosis. Treatment options include medical therapy, revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and mechanical circulatory support in cases of cardiogenic shock.

We report a case of spontaneous dissection of the left main stem coronary artery, with extension into the left coronary territory, which occurred in a 41-year-old lady, complicated by profound cardiogenic shock requiring recovery with extracorporeal mechanical circulatory support after salvage myocardial revascularization.

Spontaneous coronary artery dissection: Case series and review of literature

AIM

Spontaneous 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.

METHODS

A 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.

RESULTS

All 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.

CONCLUSIONS

Clinical 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 PRACTICE

The 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.

Myriad Cardiac Manifestation of Hyperhomocysteinemia

Homocysteine has been recognized as a risk factor for various cardiovascular manifestations including thrombosis of arterial and venous system, spontaneous dissection involving various vessels in the body including coronaries and aneurysms. Here we report a young gentleman who was diagnosed as stroke in young and found to have dilated cardiomyopathy, with left ventricular dysfunction and hyperhomocysteinemia. Now the patient was presenting with unstable angina and found to have layered left ventricular thrombus on echocardiography and spontaneous coronary artery dissection on angiography. Our patient is being followed up on optimal medical management, as he is asymptomatic with medications.

Acute ileofemoral artery thromboembolism due to left ventricle thrombi with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a very rare cause of peripheral artery thromboembolism. It is especially rare to show symptoms of acute limb ischemia without chest symptoms during a hospital visit. In this case, a rare case of SCAD led to left heart failure and caused left ventricle thrombi, which in turn caused peripheral thromboembolism.

Spontaneous coronary artery dissection as a cause of myocardial infarction

Spontaneous coronary artery dissection (SCAD) is a rare disease that is usually seen in young women in left descending coronary artery and result in events like sudden cardiac death and acute myocardial infarction. A 70-year-old man was admitted to the emergency department with chest pain which started 1 h ago during a relative’s funeral. The initial electrocardiography demonstrated 2 mm ST-segment depression in leads V1-V3 and the patient underwent emergent coronary angiography. SCAD simultaneously in two different coronary arteries [left anterior descending (LAD) artery and left circumflex (LCx)] artery was detected and SCAD in LCx artery was causing total occlusion which resulted in acute myocardial infarction. Successful stenting was performed thereafter for both lesions. In addition to the existence of SCAD simultaneously in two different coronary arteries, the presence of muscular bridge and SCAD together at the same site of the LAD artery was another interesting point which made us report this case.

Spontaneous coronary artery dissection: a case series and literature review

Spontaneous coronary artery dissection (SCAD) is a rare and often lethal cause of acute coronary syndrome, which typically affects young women and otherwise healthy individuals. SCAD can be diagnosed in patients undergoing coronary angiography and can be underestimated. Special techniques such as optical coherence tomography (OCT) and intravascular ultrasound should be used when there is suspicion of the condition. In the majority of cases, the left anterior descending (LAD) artery is involved; however, a few cases of the right coronary artery (RCA) involvement have been reported. This article describes three cases of SCAD in women of different ages, all presenting with chest pain. Coronary angiography in conjunction with OCT was used for diagnosis in two of the cases. One of the patients had involvement of the proximal RCA and underwent percutaneous coronary intervention, whereas the other two patients had mid-LAD disease and were treated conservatively with medical therapy. Presently, there are no specific guidelines for the treatment of SCAD, and therapy is individualized according to extent and severity of the condition.

Eosinophilic coronary monoarteritis

Eosinophilic coronary monoarteritis is an unfamiliar cause of acute myocardial ischemia. Most commonly, it presents as a left-sided chest pain or sudden death in middle-aged women with no traditional risk factors for coronary artery disease. Because the abrupt onset leaves almost no time for intervention, the symptoms readily lead to death, and most cases are diagnosed at necropsy. Dissection of the coronary artery wall with resultant occlusion of the lumen, which commonly affects the left anterior descending artery, is a consistent gross finding. An inflammatory infiltrate, which is predominantly composed of eosinophils in the tunica adventitia and tunica media and is often accompanied by a hematoma in between these 2 layers, is observed histologically. The etiology remains unclear, but an increase in the activity of eosinophils because of hormonal interactions during pregnancy has been suggested. Interplay of hormones is thought to culminate in the release of histolytic agents by the eosinophils, which initiate the dissection process. Currently, there is no specific treatment for eosinophilic coronary monoarteritis, but cyclophosphamide and prednisone have shown positive results in the treatment of spontaneous coronary artery dissection with unspecified periadventitial inflammation. Percutaneous coronary procedures have also resulted in favorable outcomes in a subset of patients. Because of the high, sudden death rate in eosinophilic coronary monoarteritis, deciphering the underlying pathophysiology of this almost invariably fatal disease remains both a challenge and a key to developing screening methods that will allow timely detection and thus treatment.

A case of a young, healthy woman with spontaneous coronary artery dissection associated with oral contraceptive use: Long-term residual dissection of the coronary artery

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome, typically affecting young, healthy women, particularly during the peripartum period. Oral contraceptive use is also recognized as a risk factor for SCAD. In the present report, we describe a case of a young woman with an anterior wall myocardial infarction caused by SCAD of the left anterior descending artery (LAD). The event was probably associated with the patient's oral contraceptive use. The patient underwent percutaneous coronary intervention, and she did not experience any recurrent chest pain or other cardiac symptoms. Although the coronary angiography revealed good LAD flow and no symptoms after 6 months, cardiac computed tomography and intravascular ultrasound revealed that LAD dissection was still present. We continued to closely follow-up the patient without initiating any additional intervention, and the patient has had no cardiac event for up to 4 years of follow-up. <Learning objective: We aimed to present a case of spontaneous coronary artery dissection, with a long-term residual dissection. Coronary computed tomography aided the diagnosis of the residual dissection, which was not detected by coronary angiography.>.

Spontaneous-idiopathic left anterior descending artery dissection: is watchful waiting better than immediate stenting?

Spontaneous coronary artery dissection (SCAD) is a rare, complex disease, nowadays poorly understood yet. The lack of firm recommendations about this issue is a great limitation which makes any therapeutic decision controversial. The case described is that of a young, otherwise healthy woman, who presented with an ostial dissection of the left anterior descending (LAD) artery. Due to patient's stable clinical and hemodynamic parameters, we used a cautious approach based on watchful waiting and medical therapy, postponing stenting in order to achieve a partial vessel reopening with a more comfortable access to PCI.

Spontaneous coronary artery dissection mimicking coronary spasm diagnosed by intravascular ultrasonography

Spontaneous coronary artery dissection (SCAD) is a rare and occasionally life-threatening cause of acute coronary syndrome. Patients may present with clinical scenarios ranging from angina pectoris to cardiogenic shock to sudden cardiac death, and it may be a potentially life-threatening condition if not recognized. However, its etiology, pathophysiology and optimal therapeutic strategies have not been well understood. SCAD is diagnosed on the basis of coronary angiography, but complementary techniques as such intravascular ultrasound (IVUS) and optical coherence tomography should be considered for diagnostic clarification where appropriate. Likewise, the selection of treatment strategy depends upon the clinical manifestation, location and the extent of dissection and amount of ischemic myocardium at risk. Herein, we present the case of a 35-year-old woman who presented with acute myocardial infarction. She was diagnosed by IVUS with spontaneous diffuse dissection of the left anterior descending artery without atheroma, treated with percutaneous coronary stenting, and had a favorable clinical course and was discharged on medical therapy.

Spontaneous multivessel coronary artery dissection with anomalous coronary artery

Spontaneous coronary artery dissection (SCAD) is one of the rare causes of acute coronary syndrome in young healthy individuals especially women without having any conventional risk factors for coronary artery disease. We describe a case of 34-year-old healthy man with diffuse multiple SCADs who presented with acute coronary syndrome and was managed conservatively with an uneventful course on long-term follow-up.

Multivessel spontaneous coronary artery dissection treated with staged percutanous coronary intervention in a non-postpartum female

We present a case of a 43-year-old woman who presented with a non-ST elevation myocardial infarction. During her first cardiac catheterisation, she was diagnosed with a chronic total occlusion of the right coronary artery and a flow limiting dissection of her middle left anterior descending artery. The dissection of the left anterior descending artery was stented with two overlapping everolimus-eluting stents. There were no complications from this percutaneous coronary intervention. On the following day, the patient continued to have persistent chest pain and returned to the catheterisation laboratory. It was then found that the patient had a total occlusion of the right coronary artery secondary to dissection. This was also stented with three everolimus-eluting stents with excellent clinical and angiographic results. It is important to consider spontaneous multivessel coronary dissections which can be treated successfully with percutaneous coronary intervention.

A case of sudden death due to spontaneous coronary artery dissection

Spontaneous dissection of the coronary arteries is an extremely rare event that occurs usually in middle-aged women and is mostly recognized at postmortem examination in victims of sudden death. It is a rare coronary pathologic finding whose precise incidence, etiology, pathogenesis, treatment, and evolution have not been clearly established. We present a sudden death case of a 53-year-old woman with spontaneous dissection of the left anterior descending coronary artery with eosinophilic coronary arteritis.

Pregnancy-related Spontaneous Coronary Artery Dissection: Two Case Reports and a Comprehensive Review of Literature

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, particularly seen in women during pregnancy or in the puerperium. It has a high acute phase mortality. The etiology is uncertain. Hormonal changes during pregnancy, hemodynamic stress and changes in the autoimmune status have been considered as possible etiological factors. A timely diagnosis and institution of appropriate treatment is important for a successful outcome. There is no consensus of opinion for optimal treatment. Conservative management, coronary artery bypass graft surgery, and percutaneous coronary intervention, all have been described in the literature as possible therapeutic options. Spontaneous coronary artery dissection should be considered as a differential in any young woman presenting with chest pain associated with pregnancy. We report two cases of pregnancy-associated spontaneous coronary artery dissection, both successfully managed, along with a comprehensive review of the previously published literature.

A case of spontaneous multivessel coronary artery dissection presenting with acute myocardial infarction and ventricular tachycardia

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia. Multivessel SCAD is much rarer than single vessel involvement and acute coronary syndrome remains the most common clinical presentation of a patient with SCAD. It predominantly occurs in association with atherosclerosis or in the absence of atherosclerosis. We, hereby, present a case of spontaneous multivessel coronary artery dissection in a 35-year-old male patient presenting with chest pain and ventricular tachycardia following emotional stress and discuss the etiology and treatment options.

Asymptomatic spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia that could present as angina, acute myocardial infarction, or even sudden death. It occurs more commonly in women and it has been associated with autoimmune and collagen vascular diseases. The management and prognosis in these patients depend on the initial clinical presentation and the extent of dissection. In this article, we report 2 cases of asymptomatic SCAD that were diagnosed on routine preoperative evaluation. The management options and clinical implications are discussed.

Spontaneous left main coronary artery dissection and the role of intravascular ultrasonography

OBJECTIVE

Spontaneous left main coronary artery (LMCA) dissection is a rare event with an unknown incidence and high risk of sudden cardiac death. The diagnosis of LMCA dissection is often challenging given the limitations of 2-dimensional angiography. The 3-dimensional perspective of intravascular ultrasonography (IVUS) is often indispensable in confirming or excluding the diagnosis of spontaneous LMCA dissection. We report 2 cases of spontaneous LMCA dissection with unique angiographic presentations wherein IVUS was essential in defining the extent of LMCA involvement and facilitated the subsequent referral for emergent coronary artery bypass grafting.

METHODS

Two patients presented to our facility with acute coronary syndrome prompting coronary angiography, which was notable for an unusual angiographic appearance of the LMCA. Intravascular ultrasonography was performed in each case, revealing spontaneous LMCA dissection.

RESULTS

Intravascular ultrasonography permitted the prompt diagnosis and aided in definitive surgical intervention in our 2 cases of spontaneous LMCA dissection.

CONCLUSIONS

Intravascular ultrasonography is a useful adjunctive imaging modality in the diagnosis and management of spontaneous LMCA dissection.

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 dissection of the distal obtuse marginal coronary artery: a rare cause of sudden death

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction and sudden death. It typically, but not always, occurs in healthy postpartum women without traditional risk factors for atherosclerosis. Moreover, the site of dissection usually involves the proximal, major coronary arteries: left main coronary artery and/or the left anterior descending artery, and in men, more often the right coronary artery. We report a case of sudden death caused by dissection of the obtuse marginal branch of the left circumflex artery, in a 49-year-old man, a very rare site of fatal coronary dissection.

Spontaneous coronary artery dissection mimicking acute aortic dissection

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome or sudden cardiac death, occurring predominantly in the female sex without cardiovascular risk factors. Although the etiology and pathogenesis remain uncertain, hypertension has not appeared to be one of the most important factors. This case report describes a patient with spontaneous coronary artery dissection in proximal right coronary artery who presented the signs and symptoms of acute aortic dissection. The authors postulate that hypertension may have been an important factor for the pathogenesis of the spontaneous coronary artery dissection.

Surgical management of spontaneous coronary artery dissection

Spontaneous coronary artery dissection, which causes acute coronary syndrome and can result in sudden death, is rare; but its true incidence is underestimated, since most patients die suddenly, without diagnosis. The aim of this study was to show the importance of prompt diagnosis and treatment. In reviewing the records of 5,000 consecutive patients who underwent coronary angiography between January 2001 and August 2006, we found 6 cases of spontaneous coronary artery dissection (an incidence rate of 0.12%). Five patients presented with left main coronary artery dissection and 1 patient, with right coronary artery dissection. Angioplasty with stenting failed in the patient with right coronary artery dissection. Coronary artery bypass surgery was performed in all patients. The patient with right coronary artery dissection died of sepsis on the 30th postoperative day. The other 5 patients (83.3%) are still free of symptoms, and they had negative results on stress tests at the 6- and 12-month follow-up visits after coronary artery bypass surgery. The clinical presentation of spontaneous left main coronary artery dissection was similar to that of atherosclerotic disease. However, early diagnosis of spontaneous coronary artery dissection by means of coronary angiography is of paramount importance, because urgent coronary artery bypass grafting can be lifesaving.

Catheter-Induced Left Main Coronary Artery Spiral Dissection: Stenting or Bypass? (Case Report and Literature Review)

Catheter-induced Left Main Coronary Artery (LMCA) dissection is a very uncommon but life-threatening complication of coronary intervention and requires urgent management. We report one such patient whose risk factors appear to be Coronary Artery Disease (CAD), smoking and a prior Myocardial Infarction (MI).

Acute myocardial infarction due to spontaneous coronary artery dissection treated with primary coronary angioplasty: a case report

We report the case of a young woman referred to our hospital for anterior ST-elevation myocardial infarction to be treated with primary coronary angioplasty. Angiography showed total dissection of the left anterior descending coronary artery, which was successfully treated with primary coronary angioplasty and multiple coronary stent implantation. Spontaneous coronary artery dissection is an unusual cause of acute coronary syndrome, which occurs more frequently in women with many pregnancies (our patient had eight sons before hospital admission for acute myocardial infarction). Although technically challenging, primary coronary angioplasty is a good strategy for treating coronary artery dissection.