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

The presence of thrombus in spontaneous coronary artery dissection: A systematic review of autopsy findings

Background

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome in young women. There is no consensus on optimal treatment, though a conservative approach including antiplatelet agents is commonly used. We hypothesized that most cases of SCAD would not demonstrate true lumen thrombus in the dissected artery, suggesting that anti-platelet agents might not have a role in the treatment of SCAD.

Methods

We conducted a systematic review of the published literature through March 2022 to identify pathology images from individuals who died of SCAD. The images were independently reviewed by a pathologist to assess for the presence of thrombus and inflammatory cells.

Results

We identified 40 cases from 34 publications with available pathology images and found only one case of true lumen thrombus. Additionally, we found that 53% of cases involved eosinophilic inflammation.

Conclusion

The role of antiplatelet agents in the treatment of SCAD should be re-evaluated. Further studies are needed to better understand the significance and treatment implications of eosinophilic inflammation.

Ventricular Arrhythmias in Patients with Spontaneous Coronary Artery Dissection: Findings from the Gulf Spontaneous Coronary Artery Dissection (Gulf SCAD) Registry

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome in young women, with a wide clinical spectrum of severity. Ventricular arrhythmia (VA) can occur and worsen prognosis. The current study compared in-hospital and follow-up adverse cardiovascular events in patients with and without VA at presentation.

METHODS

Eighty-three cases of SCAD were collected retrospectively from 4 Gulf countries (KSA, UAE, Kuwait, and Bahrain) during the period from January 2011 to December 2017. We divided the patients into 2 groups: those with and without VA at presentation. VA was defined as ventricular tachycardia and/or ventricular fibrillation. In-hospital (recurrent VA, cardiogenic shock, death, implantable cardioverter-defibrillator placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) events were compared among the 2 groups.

RESULTS

The median age of patients in the study was 44 (37-55) years. Forty-two (51%) were women. VA occurred in 10 (12%) patients in the first 24-hour of hospitalization, and 5 (50%) of those patients had recurrent in-hospital VA. Among those with recurrent VA, 1 died during hospitalization and 1 died within the first year following hospital discharge.

CONCLUSIONS

In-hospital adverse cardiovascular events were significantly more frequent for patients with SCAD who presented with VA. However, follow-up events were not statistically significant between those with and without VA at presentation.

Update in Spontaneous Coronary Artery Dissection

There has been increased awareness in the understanding and recognition of spontaneous coronary artery disease. Diagnosing this condition is of paramount importance as the treatment strategy differs greatly from traditional acute coronary syndrome patient. We review here the current state of management of spontaneous coronary artery disease.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

What is Sudden Cardiac Death?

Sudden cardiac death (SCD) is a rapid, unexpected death due to cardiac causes. The differential diagnosis includes diseases from all four structural divisions of the heart: the blood vessels, myocardium, valves, and conduction system. Although ischemic heart disease is a common cause of SCD, acute myocardial infarcts and/or coronary thromboses are not always detected and are not required to make the diagnosis of death due to atherosclerotic coronary disease. Some people die suddenly from heart disease with a grossly and microscopically normal heart. Molecular analysis of some of these autopsy-negative, sudden unexplained deaths (SUD) may detect putative cardiac channel mutations.

There are three SCD scenarios that are of particular interest to forensic pathologists: sudden cardiac deaths in young athletes, during criminal altercations (homicide by heart attack), and in other hostile environments. In young athletes, most sudden deaths involve cardiac disease and include cardiomyopathies, congenital coronary artery anomalies, myocarditis, and channelopathies. One must, however, consider other causes in these deaths (e.g., commotio cordis, hyperthermia, sickle cell trait). Homicide-by-heart-attack deaths are those in which the cause of death is an acute exacerbation of underlying cardiac disease, however, the manner is homicide because a criminal act triggered the lethal pathologic cascade. A sudden cardiac arrest may occur in hostile locations with resultant trauma (e.g., while driving a motor vehicle). When the event occurs in the bathtub or other body of water, the question of whether the person died naturally from heart disease or unnaturally from trauma (e.g., drowning) often arises. One should not be mislead by the initial physical surroundings of the death (i.e., in a motor vehicle collision, or swimming pool) and fail to distinguish a natural sudden death from an accidental one.