Spontaneous Coronary Artery Dissection with Pseudoaneurysm Formation Diagnosed by Intravascular Ultrasound: A Case Report

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.

[Imaging of coronary aneurysms in adults' coronary aneurysms]

Coronary aneurysms are rare and of various etiologies in adults. Natural history, modalities of management and clinical monitoring remain poorly known due to the lack of large studies and homogeneous diagnostic and follow-up criteria in the published data. Coronary angiography is, so far, the most common diagnostic tool but can overlook some partially thrombosed aneurysmal. Intracoronary imaging, particularly intravascular ultrasound, can differentiate aneurysms from pseudoaneurysms considered by some to be at greater risk of events, requiring a curative treatment. Intracoronary imaging can also help with etiological assessment and percutaneous treatment. With its growing use in the search for coronary atheromatous disease, coronary CT angiography has become a major diagnostic tool for coronary aneurysms. In addition, that it can incidentally detect coronary aneurysms, coronary CT angiography is particularly useful for giant aneurysms poorly visualized on coronary angiography or less well evaluated by intracoronary imaging. It specifies their relationship with adjacent anatomical structures. It is also a non-invasive modality of monitoring. These three imaging tools are currently the most relevant in current practice pending large studies evaluating the natural history of coronary aneurysms, with the identification of possible risk factors that could modify the management.

Spontaneous Coronary Artery Dissections: A Systematic Review

Myocardial infarction with nonobstructive coronary artery disease due to spontaneous coronary artery dissection (SCAD) accounts for 5–8% of acute coronary syndrome (ACS) presentations. The demographic characteristics, risk factors, and management of patients with SCAD differ from those with atherosclerotic disease. The objective of this review is to provide a contemporary understanding of the epidemiology, pathophysiology, clinical presentation, and management 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.

Coronary Artery Aneurysms: A Review of the Epidemiology, Pathophysiology, Diagnosis, and Treatment

Coronary artery aneurysms (CAAs) are uncommon and describe a localized dilatation of a coronary artery segment more than 1.5-fold compared with adjacent normal segments. The incidence of CAAs varies from 0.3 to 5.3%. Ever since the dawn of the interventional era, CAAs have been increasingly diagnosed on coronary angiography. Causative factors include atherosclerosis, Takayasu arteritis, congenital disorders, Kawasaki disease (KD), and percutaneous coronary intervention. The natural history of CAAs remains unclear; however, several recent studies have postulated the underlying molecular mechanisms of CAAs, and genome-wide association studies have revealed several genetic predispositions to CAA. Controversies persist regarding the management of CAAs, and emerging findings support the importance of an early diagnosis in patients predisposed to CAAs, such as in children with KD. This review aims to summarize the present knowledge of CAAs and collate the recent advances regarding the epidemiology, etiology, pathophysiology, diagnosis, and treatment of this disease.

Diagnosis and treatment of spontaneous coronary artery pseudoaneurysm: Rare anomaly with potentially significant clinical implications

Spontaneous coronary artery pseudoaneurysm (PSA, false aneurysm) is an extremely rare occurrence with the precise incidence unknown. It is defined as an outwardly bulging monolayer or double layer within the coronary artery that lacks all 3 layers (intima, media, and adventitia) of the arterial wall. Coronary PSA commonly occurs from arterial dissection or perforation induced by catheter intervention, infection, pregnancy, or trauma. Traumatic dissection or perforation of the coronary artery after a percutaneous coronary intervention (PCI) remains the most common cause. Such cases may progress to myocardial ischemia, acute myocardial infarction, or acute coronary artery rupture causing death from cardiac tamponade. Intravascular ultrasound or cardiac computed tomography may aid in the diagnosis. Treatment options include PCI with a covered stent, bare or drug-eluting stent, coil embolization, coronary artery bypass graft with isolation of the PSA, or conservative management with vigilant clinical follow-up. In this review, we sought to describe the diagnosis, etiology, treatment, and the limited literature on spontaneous coronary artery PSA. © 2017 Wiley Periodicals, Inc.

Very Late Development of Coronary Artery Aneurysm with Total Occlusion following Sirolimus-Eluting Stent Implantation

A 41-year-old African American woman presented with chest pain and was found to have non-ST segment elevation myocardial infarction with a peak cardiac troponin I of 28.5. Elective cardiac catheterization revealed a 70% ostial left anterior descending (LAD) artery stenosis. The patient underwent percutaneous coronary intervention and a sirolimus-eluting stent (Cypher, Miami, FL, 3.5 × 8 mm) was successfully deployed. Three years after stent implantation, the patient presented with recurrent angina. Repeat coronary angiography revealed a large aneurysm involving the proximal portion of the stent with a total occlusion at the mid to distal portion of the stent with collaterals to LAD from left circumflex artery. The patient underwent coronary artery bypass surgery with left internal mammary artery graft to LAD and ligation of LAD at its origin proximal to the aneurysm.

Spontaneous coronary artery dissection after heavy lifting in a 25-year-old man with coronary risk factors

Spontaneous coronary artery dissection (SCAD) is a clinical condition rarely leading to acute myocardial infarction (AMI). We report the case of SCAD presenting AMI in a 25-year-old man with coronary risk factors after strenuous exercise, who was successfully treated with systemic thrombolysis. Coronary angiography revealed spiral dissection of the proximal part of the left anterior descending artery. The present case supports the occurrence of SCAD as a cause of AMI in young male patients who have coronary risk factors, after heavy lifting.