A case report of recurrent spontaneous coronary artery dissection and Takotsubo cardiomyopathy: a treatment dilemma

Spontaneous coronary artery dissection in patients with prior psychophysical stress: a systematic review of case reports and case series

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome, particularly in younger women. Due to limited information about SCAD, case reports and case series can provide valuable insights into its features and management. This study aimed to comprehensively evaluate the features of SCAD patients who experienced psychophysical stress before the SCAD event.

METHODS

We conducted an electronic search of PubMed, Scopus, and Web of Science from inception until January 7, 2023. We included case reports or series that described patients with SCAD who had experienced psychophysical stress before SCAD. Patients with pregnancy-associated SCAD were excluded from our analysis.

RESULTS

In total, we included 93 case reports or series describing 105 patients with SCAD. The average patient age was 44.29 ± 13.05 years and a total of 44 (41.9%) of patients were male. Among the included SCAD patients the most prevalent comorbidities were fibromuscular dysplasia (FMD) and hypertension with the prevalence of 36.4 and 21.9%, respectively. Preceding physical stress was more frequently reported in men than in women; 38 out of 44 (86.4%) men reported physical stress, while 36 out of 61 (59.1%) females reported physical stress (p value = 0.009). On the other hand, the opposite was true for emotional stress (men: 6 (13.6%)), women: 29 (47.6%), p value < 0.001). Coronary angiography was the main diagnostic tool. The most frequently involved artery was the left anterior descending (LAD) (62.9%). In our study, recurrence of SCAD due to either the progression of a previous lesion or new SCAD in another coronary location occurred more frequently in those treated conservatively, however the observed difference was not statistically significant (p value = 0.138).

CONCLUSION

While physical stress seems to precede SCAD in most cases, emotional stress is implicated in females more than males.

Spontaneous coronary artery dissection-associated takotsubo syndrome: A systematic review of case reports

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is underdiagnosed and requires comprehensive angiographic findings. Few SCAD occurrences have a comparable clinical appearance as takotsubo syndrome (TTS) or exist simultaneously, making it challenging for clinicians to treat and manage. Case reports lack consolidated data. We examined SCAD-TTS case reports.

AIM

To conduct a systematic review of available case reports on SCAD in order to investigate its potential association with TTS.

METHODS

SCAD-associated TTS case reports were reviewed after thoroughly screening PubMed, EMBASE, Scopus, and Google Scholar databases till January 2023. Case reports described demographics, comorbidities, imaging, management, and results.

RESULTS

Twelve articles about 20 female patients were analyzed. 30% of patients (n = 6, > 60 years) were elderly (mean age 56.2 ± 9.07 years, range 36-70 years). Canada has 9 cases, United States 3, Australia 3, Sweden 2, Japan, Denmark, and France 1. Only 5 reports identified emotional stressors in these cases while 4 reports showed physical triggers for TTS. Nine had hypertension, 2 had hyperlipidemia, and 1 had prediabetes. 5 patients (25%) smoked. 10 (50%) troponin-positive myocardial infarction patients reported chest discomfort. 11 (55%) of 20 instances had TTS/SCAD. 12 (60%) of 20 patients exhibited ST elevation and 3 (15%) had T wave inversion on electrocardiogram. 19/20 patients had elevated troponin. 9 (45%) of 20 people had apical akinesis with TTS ballooning on cardiac imaging. All 20 exhibited echocardiographic wall motion abnormalities. 19 (95%) of 20 coronary angiography cases had SCAD. 10 of 19 SCAD patients had left anterior descending, 2 diagonal, and 2 left circumflex coronary artery involvement. 7 of 20 patients had left ventricular ejection fraction (LVEF) data. LVEF averaged 38.78 ± 7.35%. 5 (25%) of the 20 cases underwent dual antiplatelet therapy. Three (15%) of 20 cases experienced occasional ectopic ventricular complexes, Mobitz ll AV block, and paroxysmal atrial fibrillation. All 20 cases recovered and survived.

CONCLUSION

Given the clinical similarities and challenges in detecting TTS and SCAD, this subset needs more research to raise awareness and reduce morbidity.

Rare Sequela of Spontaneous Coronary Artery Dissection

Non-atherosclerotic spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Here, we report a case of acute ischemic mitral regurgitation (MR) due to SCAD of the left main coronary artery. Given the extent of the acute ischemic MR and multi-vessel disease, the decision was made to pursue coronary artery bypass graft surgery and annuloplasty mitral valve ring repair.

"Obesity paradox" and takotsubo syndrome

Background

An "obesity paradox" has been reported in patients with hypertension and heart failure, in which obese patients fare better than patients with normal-weight. The purpose of this study was to determine whether there is an "obesity paradox" in patients with takotsubo syndrome (TTS).

Methods

The prevalence of obesity in databases/registries of patients with TTS was compared to the prevalence of obesity in world general populations. Obese patients with TTS were explored regarding the stress triggers precipitating the illness, hospital outcome, and post-discharge readmission. Finally, the literature on the "obesity paradox" was explored to understand how it could be applied to TTS.

Results

A prevalence of obesity of ∼10-11% has been reported in large cohorts of patients with TTS, which represents 1/3 to ¼ of the prevalence reported in worldwide general populations, suggesting that, normal-weight than obese individuals, are more predisposed to develop TTS, with the latter nevertheless also suffering TTS, when triggered by enormous physical stresses. Obese patients with TTS are likely to have milder hospital outcomes, lower mortality, and lower rate of early readmission. A greater sympathetic nervous system (SNS) response in a number of hyperadrenergic states in normal-weight than obese patients, may explain findings in patients with TTS.

Conclusions

An "obesity paradox" has been identified in patients with TTS. Reporting on body mass index and other markers of obesity in patients with TTS, and implementing some recommendations on monitoring noninvasively the SNS in patients with TTS, may solidify that obesity has a preventive/ameliorating effect for TTS development and its clinical course.

De Winter's pattern: an uncommon but very important electrocardiographic sign in the prompt recognition of spontaneous occlusive coronary artery dissection in young patients with chest pain (a case report)

Chest pain is a clinical symptom for immediate consultation, and electrocardiogram (ECG) is a valuable diagnostic tool for use in the emergency room. Although the ST- elevation myocardial infarction (STEMI) requires urgent management, there are other ECG high-risk findings which are associated with adverse outcomes or imminent acute myocardial infarction (AMI). This is a case of STEMI equivalent pattern such as de Winter. As this ECG pattern is uncommon, it may be misinterpreted in the emergency department. We report a misinterpretation of de Winter's pattern (dWp) in a young woman referred to the emergency department for chest pain, feeling of suffocation and hemodynamic instability who undergone reteplase treatment with the suspicion of acute massive pulmonary embolism but developed cardiogenic shock as a result of extensive myocardial infarction due to spontaneous dissection of the left anterior descending coronary artery. A prompt diagnosis of de Winter's pattern and early angiography to detect the underlying cause of clinical manifestation can be lifesaving.

Coexistence of Spontaneous Coronary Artery Dissection, Takotsubo Cardiomyopathy, and Myocardial Bridge

We report a case of spontaneous coronary artery dissection located next to a myocardial bridge in a patient with concomitant takotsubo cardiomyopathy. A fusion image with multidetector-row computed tomography and single-photon emission computed tomography played an important role in the diagnosis of these lesions. (Level of Difficulty: Advanced.)

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.

The Chicken or the Egg? An Interesting Case Presentation of Spontaneous Coronary Artery Dissection Versus Takotsubo Cardiomyopathy

This is an interesting cardiovascular imaging and coronary angiography case of a 67-year-old female patient who presented with chest pain, abnormal electrocardiogram (EKG), and heart failure who was subsequently found to have spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TCM) on imaging studies. The case presentation highlights the importance of imaging studies and prompt diagnosis in these patients. This study may also highlight the need for early medical intervention in patients with suspected systolic dysfunction due to either of these pathophysiologic processes.