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Yoon SG, Song YJ, Song YS, Park J, Kim S, Kim DK, Kim KH, Kim DI, Kim HK, Lee DA. Concurrent spontaneous coronary dissection and reversible cerebral vasoconstriction syndrome during postnatal care. Egypt Heart J 2024; 76:33. [PMID: 38498256 PMCID: PMC10948679 DOI: 10.1186/s43044-024-00464-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Pregnancy-associated spontaneous coronary artery dissection (SCAD) and reversible cerebral vasoconstriction syndrome (RCVS) are rare conditions that may occur during pregnancy and the postpartum period. The coexistence of both diseases may pose a risk to patients, potentially resulting in a variety of complications and clinical manifestations. This is considered the first case of a patient who successfully recovered from a critical condition in the postpartum period, with contemporaneous SCAD and RCVS. CASE PRESENTATION A 33-year-old female with no known medical history was referred to the emergency department after experiencing cardiac arrest, which occurred 1 week after giving birth to her third child. She complained of sudden anterior squeezing chest pain, accompanied by a headache, and eventually collapsed due to ventricular fibrillation with seizure. She was successfully resuscitated after receiving basic life support. She showed an alert mentality and did not experience any further seizure events or additional neurological symptoms. Although vital sign remained stable, the level of highly sensitive troponin I was significantly elevated. Electrocardiography revealed sinus rhythm with T-wave inversion at V1-4, while chest computed tomography (CT) demonstrated severe aspiration pneumonia. The patient was admitted to the intensive care unit due to a high requirement of O2 supply. A consultation with the neurologic department and a brain magnetic resonance angiography (MRA) were conducted for the thunderclap headache. The brain MRA demonstrated stenosis in the basilar artery, the right M2 segment, and bilateral A1 segments, along with sulcal hyperintensity on post-contrast fluid-attenuated inversion recovery (FLAIR) suggesting blood-brain barrier breakdown due to vasoconstriction. Formal echocardiography showed regional wall motion abnormality in the left anterior descending artery (LAD) territory. After the improvement of pneumonia, a coronary angiography was performed, revealing diffuse luminal narrowing from the mid to distal LAD due to a long segmental, extensive dissection. We decided to maintain the medical therapy. A follow-up coronary CT angiography performed 6 months later revealed complete remission of the dissected coronary vessel, and a brain MRA checked 3 months later showed resolved vasoconstriction of the relevant cerebral vessels. CONCLUSIONS The physicians must be aware of pregnancy-associated complications in certain patients. Clear diagnoses and proper treatments are required in pregnant patients who may be exposed to multiple acute conditions, in order to reduce complications and achieve favorable outcomes.
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Affiliation(s)
- Sang Gon Yoon
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Yeo-Jeong Song
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea.
| | - Yun-Seok Song
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Jino Park
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Seunghwan Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Dong-Kie Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Ki-Hun Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Doo-Il Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, 1435 Jwa-dong, Haeundae-gu, Busan, 48108, Korea
| | - Hyun Kuk Kim
- Division of Pulmonology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea
| | - Dong Ah Lee
- Department of Neurology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea
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La S, Beltrame J, Tavella R. Sex-specific and ethnicity-specific differences in MINOCA. Nat Rev Cardiol 2024; 21:192-202. [PMID: 37775559 DOI: 10.1038/s41569-023-00927-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/01/2023]
Abstract
Suspected myocardial infarction with non-obstructive coronary arteries (MINOCA) has received increasing attention over the past decade. Given the heterogeneity in the mechanisms underlying acute myocardial infarction in the absence of obstructive coronary arteries, the syndrome of MINOCA is considered a working diagnosis that requires further investigation after diagnostic angiography studies have been performed, including coronary magnetic resonance angiography and functional angiography. Although once considered an infrequent and low-risk form of myocardial infarction, recent data have shown that the prognosis of MINOCA is not as benign as previously assumed. However, despite increasing awareness of the condition, many questions remain regarding the diagnosis, risk stratification and treatment of MINOCA. Women seem to be more susceptible to MINOCA, but studies on the sex-specific differences of the disease are scarce. Similarly, ethnicity-specific factors might explain discrepancies in the observed prevalence or underlying pathophysiological mechanisms of MINOCA but data are also scarce. Therefore, in this Review, we provide an update on the latest evidence available on the sex-specific and ethnicity-specific differences in the clinical features, pathophysiological mechanisms, treatment and prognosis of MINOCA.
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Affiliation(s)
- Sarena La
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John Beltrame
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Rosanna Tavella
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Rathi AC, Nagtode N, Chandra V, Pathade AG, Yelne S. Critical Insights Into the Management of Postpartum Left Main Spontaneous Coronary Artery Dissection: Current Strategies and Future Directions. Cureus 2023; 15:e44622. [PMID: 37799221 PMCID: PMC10548014 DOI: 10.7759/cureus.44622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 09/03/2023] [Indexed: 10/07/2023] Open
Abstract
This review article delves into the multifaceted realm of postpartum left main spontaneous coronary artery dissection (PLMSCAD), an infrequent yet critical condition affecting women during the postpartum period. Through a comprehensive exploration of its pathophysiology, clinical presentation, diagnosis, management strategies, and future directions, this review provides a holistic understanding of PLMSCAD's complexities. The article highlights challenges in diagnosis due to overlapping symptoms and underscores the significance of prompt recognition and tailored interventions. Current management strategies, encompassing medical and interventional approaches, are analysed in the context of their short-term and long-term impact on patient outcomes. Ethical considerations and the role of patient education and support networks are explored, shedding light on the broader psychosocial dimensions of PLMSCAD management. As emerging research reveals insights into genetic influences, hormonal dynamics, and the prognosis of affected individuals, this review emphasises the necessity of collaborative research endeavours and data sharing to enhance our understanding and guide future strategies. Ultimately, this review underscores the urgency of addressing the unique needs of women experiencing PLMSCAD, urging ongoing research, multidisciplinary collaboration, and a patient-centred approach to optimise maternal health outcomes and well-being.
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Affiliation(s)
- Arya C Rathi
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nikhilesh Nagtode
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vaibhav Chandra
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aniket G Pathade
- Research and Development, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Seema Yelne
- Nursing, Shalinitai Meghe College of Nursing, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Zanchi J, Miric D, Giunio L, Bradaric Slujo A, Lozo M, Erceg D, Orsulic D, Borovac JA. Conservative Management of Spontaneous Left Main Coronary Artery Dissection (SCAD) Triggered by Emotional Stress in the Late Postpartum Period: Case Report and Pathophysiology. PATHOPHYSIOLOGY 2022; 29:610-618. [PMID: 36412632 PMCID: PMC9680376 DOI: 10.3390/pathophysiology29040047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/22/2022] [Indexed: 12/14/2022] Open
Abstract
A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability.
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Affiliation(s)
- Jaksa Zanchi
- Division of Interventional Cardiology, Clinic for Heart and Vascular Diseases, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
| | - Dino Miric
- Division of Interventional Cardiology, Clinic for Heart and Vascular Diseases, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
| | - Lovel Giunio
- Division of Interventional Cardiology, Clinic for Heart and Vascular Diseases, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
| | - Anteo Bradaric Slujo
- Division of Interventional Cardiology, Clinic for Heart and Vascular Diseases, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia
| | - Mislav Lozo
- Division of Interventional Cardiology, Clinic for Heart and Vascular Diseases, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
| | - Duje Erceg
- Clinic for Anaesthesiology, Reanimatology and Intensive Care, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
| | - Duje Orsulic
- Department of Cardiac Surgery, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
| | - Josip A. Borovac
- Division of Interventional Cardiology, Clinic for Heart and Vascular Diseases, University Hospital of Split (KBC Split), Spinciceva 1, 21000 Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia
- Correspondence: ; Tel.: +385-92-172-13-14
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5
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Spontaneous coronary artery dissection in systemic lupus erythematosus: case-based review. Rheumatol Int 2019; 39:1821-1827. [PMID: 31227856 DOI: 10.1007/s00296-019-04351-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/15/2019] [Indexed: 01/05/2023]
Abstract
Patients with systemic lupus erythematosus (SLE) present an increased prevalence of coronary heart disease. The majority of cases of acute coronary syndrome (ACS) in patients with SLE are due to atherosclerosis. Less common causes include thrombosis of an angiographically normal coronary artery and coronary vasculitis. Spontaneous coronary artery dissection (SCAD) is a rare cause of ACS in these patients. We report the case of a 53-year-old female diagnosed of SLE presenting with an ACS caused by SCAD. She was treated medically and her clinical course was favorable. A literature search identified seven additional cases of SCAD associated with SLE. The main clinical features found in these reports are revised. ACS caused by SCAD in SLE patients is a condition likely under-reported in literature. SCAD should be suspected in patients with SLE and ACS, especially in younger women without evident cardiovascular risk factors. An early accurate diagnosis of SCAD is key to provide specific treatment, which differs from that of usual atherosclerotic ACS.
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6
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Chongprasertpon N, Ibrahim A, Goggins M, Kiernan T. Chronic spontaneous coronary artery dissection in association with antiphospholipid syndrome presenting as stable angina. BMJ Case Rep 2019; 12:12/3/e227674. [PMID: 30872339 DOI: 10.1136/bcr-2018-227674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A 52-year-old man presented to our cardiology service for an elective diagnostic coronary angiogram for risk stratification in the context of stable angina. He was diagnosed with antiphospholipid syndrome 2 years prior and had three known thrombotic episodes in the form of a stroke, retinal artery occlusion and deep vein thrombosis. Our initial differential was atherosclerotic coronary artery disease, however, coronary angiography demonstrated a dominant right coronary artery with a long segment of chronic spontaneous dissection distally but with thrombolysis in myocardial infarction III flow. He was treated medically with antianginals which rendered him asymptomatic and is currently on regular follow-up in the cardiology outpatient department.
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Affiliation(s)
| | - Abdalla Ibrahim
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Michael Goggins
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Thomas Kiernan
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
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7
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Matshela MR. Ischaemic heart disease and pregnancy: the tale of two stories. Cardiovasc J Afr 2018; 29:e8-e12. [PMID: 29583151 PMCID: PMC6008903 DOI: 10.5830/cvja-2017-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/07/2017] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Mamotabo R Matshela
- University of KwaZulu-Natal, Durban; Mediclinic Heart Hospital, Pretoria, South Africa; London School of Economics and Political Science, London, UK.
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8
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Turtay MG, Cansel M, Oguzturk H, Yumrutepe S. Spontaneous Coronary Artery Dissection Seen in the Postpartum Period. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791001700312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. It is usually seen during pregnancy and the postpartum period of middle-aged women. Coronary angiography is important in diagnosis and treatment planning. Treatment modalities are mainly medical therapy, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty and/or stenting. Thrombolytics appear to be relatively contraindicated. This case report deals with the diagnosis, treatment and clinical presentation of a 37-year-old woman who had spontaneous coronary artery dissection emerging on the fourth day postpartum.
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Affiliation(s)
| | - M Cansel
- Inonu University Faculty of Medicine, Department of Cardiology, Turgut Ozal Medical Center, Malatya, Turkey
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9
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Havakuk O, Goland S, Mehra A, Elkayam U. Pregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.004941. [PMID: 28302642 DOI: 10.1161/circinterventions.117.004941] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/14/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Because of the rarity of this condition, information on pregnancy-associated spontaneous coronary artery dissection is limited. We reviewed a large number of contemporary pregnancy-associated spontaneous coronary artery dissection cases in an attempt to define the clinical characteristics and provide management recommendations. METHODS AND RESULTS A literature search for cases of pregnancy-associated spontaneous coronary artery dissection reported between 2000 and 2015 included 120 cases; 75% presented with ST-segment-elevation myocardial infarction, and 80% had anterior myocardial infarction. Left anterior descending coronary artery was involved in 72% of cases, left main segment in 36%, and 40% had multivessel spontaneous coronary artery dissection. Ejection fraction was reduced to <40% in 44% of cases. Percutaneous coronary intervention was successful in only 50% of cases. Coronary artery bypass surgery was performed in 44 cases because of complex anatomy, hemodynamic instability, or failed percutaneous coronary intervention. Maternal complications included cardiogenic shock (24%), mechanical support (28%), urgent percutaneous coronary intervention (28%), urgent coronary artery bypass surgery (27.5%), maternal mortality (4%), and fetal mortality (2.5%). During follow-up for 305±111 days, there was a high incidence of symptoms because of persistent or new spontaneous coronary artery dissections, and 5 women needed heart transplantation or ventricular assist device implantation. CONCLUSIONS Pregnancy-associated spontaneous coronary artery dissection is commonly associated with left anterior descending, left main, and multivessel involvement, which leads to a high incidence of reduced ejection fraction, and life-threatening maternal and fetal complications. Percutaneous coronary intervention is associated with low success rate and high likelihood of complications, and coronary artery bypass surgery is often required. Recurrent ischemic events because of persistent or new spontaneous coronary artery dissection are common during long-term follow-up.
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Affiliation(s)
- Ofer Havakuk
- From the Division of Cardiovascular Medicine, Department of Medicine and Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Sorel Goland
- From the Division of Cardiovascular Medicine, Department of Medicine and Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Anil Mehra
- From the Division of Cardiovascular Medicine, Department of Medicine and Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Uri Elkayam
- From the Division of Cardiovascular Medicine, Department of Medicine and Department of Obstetrics and Gynecology, University of Southern California, Los Angeles.
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10
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Sheikh AS, O’Sullivan M. Pregnancy-related Spontaneous Coronary Artery Dissection: Two Case Reports and a Comprehensive Review of Literature. Heart Views 2012; 13:53-65. [PMID: 22919449 PMCID: PMC3424780 DOI: 10.4103/1995-705x.99229] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Azeem S Sheikh
- Department of Cardiology, Southend University Hospital NHS Foundation Trust, Essex, UK
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11
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Houck PD, Strimel WJ, Gantt DS, Linz WJ. Should we establish a new protocol for the treatment of peripartum myocardial infarction? Tex Heart Inst J 2012; 39:244-248. [PMID: 22740744 PMCID: PMC3384054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Peripartum myocardial infarction is a rare event that is associated with high mortality rates. The differential diagnosis includes coronary artery dissection, coronary artery thrombosis, vascular spasm, and stenosis. Our evaluation of 2 cases over a 5-year time period has led to a hypothesis that peripartum myocardial infarction is an immune-mediated event secondary to coronary endothelial sensitization by fetal antigen. In our patients, we supplemented standard medical therapy with immunotherapy consisting of corticosteroids, plasmapheresis, and intravenous immunoglobulin. Herein, we present our most recent case-that of a 29-year-old black woman (gravida V, para IV), 2 weeks postpartum with no relevant medical history. She presented with a 1-week history of chest pain. Initial electrocardiographic and cardiac biomarkers were consistent with acute coronary syndrome. Echocardiography revealed reduced systolic function with inferior-wall hypokinesis. Angiography revealed diffuse disease with occlusion of the left anterior descending coronary artery not amenable to revascularization. We were successful in treating the myocardial infarction without the use of catheter-based interventions, by modifying the immunologic abnormalities. Two cases do not make a protocol. Yet we believe that this case and our earlier case lend credence to the hypothesis that peripartum myocardial infarction arises from sensitization by fetal antigens. This concept and the immune-modifying treatment protocol that we propose might also assist in understanding and treating other inflammatory-disease states such as peripartum cardiomyopathy and standard acute myocardial infarction. All of this warrants further investigation.
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Affiliation(s)
- Philip D Houck
- Division of Cardiology, Department of Medicine, Scott & White Healthcare, Temple, Texas 76508, USA.
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12
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Nisar MK, Mya T. Spontaneous coronary artery dissection in the context of positive anticardiolipin antibodies and clinically undiagnosed systemic lupus erythematosus. Lupus 2011; 20:1436-8. [PMID: 21768175 DOI: 10.1177/0961203311406765] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Spontaneous coronary artery dissection (SCAD) is an extremely uncommon condition that can lead to fatal acute myocardial infarction. There have been very few case reports of SCAD in patients with systemic lupus erythematosus (SLE) and even fewer in association with antiphospholipid antibodies - mainly postpartum. This is the first reported case of SCAD in a patient who was confirmed to have SLE and tested positive for anticardiolipin antibody and lupus anticoagulant. This case demonstrates the importance of carefully considering the differential diagnoses of SCAD at presentation. It also highlights the need for further research to explore the link between SLE, antiphospholipid antibodies and SCAD.
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Affiliation(s)
- M K Nisar
- Rheumatology Department, Luton and Dunstable NHS Trust, Luton, UK.
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13
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Hunt B, Chua R, Bett N. Conservative Treatment of Spontaneous Dissection of Multiple Coronary Arteries. Heart Lung Circ 2010; 19:678-80. [DOI: 10.1016/j.hlc.2010.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 04/15/2010] [Accepted: 07/08/2010] [Indexed: 10/19/2022]
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14
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Rajendra N, Lim F, Shaukat N. Spontaneous coronary artery dissection presenting as an ischaemic stroke in a middle-aged man with anti-cardiolipin antibodies: a case report. J Med Case Rep 2010; 4:94. [PMID: 20334675 PMCID: PMC2848682 DOI: 10.1186/1752-1947-4-94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Accepted: 03/24/2010] [Indexed: 11/12/2022] Open
Abstract
Introduction Cerebrovascular disease is a major cause of mortality and morbidity worldwide. Ischemic stroke is the most common manifestation, encompassing a wide variety of causative mechanisms. We present the case of a middle-aged male patient with spontaneous coronary artery dissection in the presence of anti-cardiolipin antibodies, leading to left ventricular thrombus and presenting with stroke. Case presentation A 56-year-old Caucasian man presented with dysarthria and right-sided weakness. There was a history of chest pain with autonomic symptoms four days earlier. Examination revealed right-sided hemiparesis. Electrocardiogram showed sinus rhythm with anterior Q waves. Magnetic resonance imaging of the brain showed large left parietal and smaller multiple cerebral infarcts. Echocardiogram showed anterior wall and apical akinesis with a large mural thrombus. Anti-cardiolipin antibodies immunoglobulin G and immunoglobulin M were strongly positive. Coronary angiography showed dissection of the mid left anterior descending artery with normal flow down the distal vessel. He was treated conservatively with anticoagulation and secondary prevention. He was in good health when seen in clinic four months later. Conclusion We highlight the importance of a comprehensive approach at obtaining the correct diagnosis, input of different specialities and the fact that the presence of anti-cardiolipin antibodies is associated with coronary artery dissection in a middle-aged male patient whose presentation was stroke.
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Affiliation(s)
- Ns Rajendra
- Department of Cardiology, Kettering General Hospital, Rothwell Road, Kettering NN16 8UZ, UK.
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15
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John SG, Pillai U, Vaidyan PB, Ishiyama T. Spontaneous renal artery dissection. MISSOURI MEDICINE 2010; 107:124-126. [PMID: 20446520 PMCID: PMC6188271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Isolated spontaneous dissection of renal arteries or its branches are extremely rare. Most cases of renal artery dissection are associated with underlying pathology of the renal arteries. We report a case of spontaneous dissection of the left main renal artery and infarction of the left kidney with positive antiphospholipid antibody. Extensive work up of the patient including imaging studies confirmed the diagnosis of SRAD. Antiphospholipid antibodies may have a role in the pathogenesis of arterial dissection by causing endothelial dysfunction. This is a first literature report.
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Affiliation(s)
- Santhosh G John
- Department of Internal Medicine, Saint Mary's Health Center in St. Louis, USA.
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16
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Collyer M, Bellenger N, Nachimuthu P, Parasuraman R, Taylor MJO. Postpartum coronary artery dissection. J OBSTET GYNAECOL 2009; 28:451-3. [DOI: 10.1080/01443610802163633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Appleby CE, Barolet A, Ing D, Ross J, Schwartz L, Seidelin P, Silversides C, Horlick E. Contemporary management of pregnancy-related coronary artery dissection: A single-centre experience and literature review. Exp Clin Cardiol 2009; 14:e8-e16. [PMID: 19492033 PMCID: PMC2689090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 02/18/2009] [Indexed: 05/27/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) is an infrequent event that is most commonly associated with pregnant women or those in the postpartum period. Because of its rarity, the literature describing this condition is confined to sporadic case reports, with few reporting long-term follow-up, and no clear consensus exists on the optimal treatment strategy for these patients. The present article reports a single-centre experience with SCAD, highlighting the issues surrounding its management with a brief description of five cases of pregnancy-associated coronary dissection. The treatment used in these cases ranged from a conservative medical approach to surgical and percutaneous intervention, with one patient proceeding to transplantation. Four of the cases have long-term angiographic follow-up.In addition, a comprehensive review of all previously published cases is presented, and temporal trends in the management strategy are highlighted. Possible pathophysiological mechanisms pertaining to this condition, and the complex diagnostic and therapeutic issues involved, which may affect both patient and fetus, are discussed. Finally, an optimal approach to patients with SCAD, informed by our experience and literature review, is described.
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Affiliation(s)
- Clare E Appleby
- Correspondence: Dr Clare E Appleby, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, United Kingdom. E-mail
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18
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Van den Branden B, Bruggeling W, Corbeij H, Dunselman P. Spontaneous coronary artery dissection in the postpartum period. Neth Heart J 2008; 16:412-4. [PMID: 19127318 PMCID: PMC2612109 DOI: 10.1007/bf03086188] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Spontaneous coronary artery dissection is a very uncommon cause of acute coronary syndrome. It occurs predominantly in young to middle-aged women during or after pregnancy. The aetiology remains uncertain. Possible factors are hormonal changes, haemodynamic stress and changes in autoimmune status. In case of single-vessel dissection and normal blood flow, conservative treatment often leads to complete angiographic resolution. This case report describes the clinical presentation, diagnosis and therapy of spontaneous coronary artery dissection in a 37-year-old woman in the postpartum period. (Neth Heart J 2008;16:412-4.).
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Affiliation(s)
- B.J.L. Van den Branden
- Department of Cardiology, Amphia Hospital, Breda; currently working at St Anthonius Hospital, Nieuwegein, the Netherlands
| | | | - H.M.A. Corbeij
- Department of Cardiology, Amphia Hospital, Breda, the Netherlands
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19
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Patel KP, Sotolongo RP, Myrick TW. Off-pump coronary artery bypass grafting for spontaneous coronary dissection in a 26-year-old patient two weeks post-partum: a case report and review. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2008; 40:127-129. [PMID: 18705549 PMCID: PMC4680634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Spontaneous coronary artery dissections are an infrequent cause of myocardial infarction and have been reported in late stages of pregnancy and in the puerperium phase. We report a case of a 26-year-old post-partum woman who was diagnosed with a spiral coronary dissection of the left anterior descending artery, with a compromised diagonal branch. She underwent an emergent surgical revascularization without the use of cardiopulmonary bypass. The patient's in-hospital clinical course, prognosis, treatment, and potential etiologies are discussed.
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Affiliation(s)
- Kirti P Patel
- Department of Surgery, Memorial Hermann Baptist Hospital, Southeast Texas Cardiology Associated Cardiovascular and Thoracic Surgeons, Beaumont, Texas, USA.
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20
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Kim SH, Kim MK, Kim EJ, Park WJ, Choi YJ, Rhim CY. Spontaneous coronary artery dissection mimicking acute aortic dissection. Angiology 2008; 59:382-4. [PMID: 18388076 DOI: 10.1177/0003319707304324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Seong Hwan Kim
- Department of Internal Medicine, Division of Cardiology, Hallym University Hangang, Sacred Heart Hospital, Yeoungdeungpo-gu, Seoul, South Korea.
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21
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Belizna CC, Richard V, Primard E, Kerleau JM, Cailleux N, Louvel JP, Marie I, Hamidou M, Thuillez C, Lévesque H. Early atheroma in primary and secondary antiphospholipid syndrome: an intrinsic finding. Semin Arthritis Rheum 2007; 37:373-80. [PMID: 17977581 DOI: 10.1016/j.semarthrit.2007.08.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 08/08/2007] [Accepted: 08/20/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The relationship between atherosclerosis and the antiphospholipid syndrome (APS) is unclear. This study compared intima-media thickness (IMT), arterial stiffness, and presence of plaques in APS patients and controls to evaluate the risk of atherosclerosis in this patient population. The study also explored the relationship between these parameters and cardiovascular risk factors. METHODS Carotid and femoral IMT and stiffness were measured in 58 APS patients and 58 controls. In addition, antiphospholipid antibodies and cardiovascular risk factors were investigated and other systemic lupus erythematosus (SLE)-related serologic parameters were measured. Details of the patients' previous medical history and information regarding disease treatment were analyzed. RESULTS A significant difference was found between IMT, arterial stiffness, and the presence of plaques in patients and controls (P<0.05). All of these parameters were independent of cardiovascular risk factors. No differences in these parameters were found between patients with primary APS and those with secondary APS, or between patients with thrombosis and those with obstetric manifestations. There was no correlation between SLE disease activity and atheroma. Patients with plaques had taken a lower total dose of corticosteroids and/or hydroxychloroquine. CONCLUSIONS Some markers of early atherosclerosis could be detected in both primary and secondary APS, irrespective of clinical manifestations. These data suggest that atherosclerosis might be an intrinsic finding in APS patients, independent of cardiovascular risk factors, and that immunosuppressive treatment may prevent atherosclerosis.
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Affiliation(s)
- Cristina C Belizna
- Department of Internal Medicine, Rouen University Hospital, Rouen, France.
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22
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Hayes CR, Lewis D. Spontaneous coronary artery dissection of the left circumflex artery causing cardiac tamponade and presenting with atrial fibrillation: a case report and review of the literature. Angiology 2007; 58:630-5. [PMID: 17901453 DOI: 10.1177/0003319707304532] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spontaneous coronary artery dissection is rare. When it does occur, it can present in a myriad of ways and can mimic more common clinical scenarios. Undiagnosed it can be fatal. In this article, the authors present a case of coronary artery dissection in a middle aged man presenting as fast atrial fibrillation with hemodynamic compromise. He was unsuccessfully cardioverted and later arrested and died. Postmortem showed a ruptured dissection of the left circumflex artery causing cardiac tamponade and death. Incidence, associations, pathophysiology, investigations, and treatment options are reviewed.
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23
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Reed RK, Malaiapan Y, Meredith IT. Spontaneous Coronary Artery Dissection in a Female with Antiphospholipid Syndrome. Heart Lung Circ 2007; 16:120-2. [PMID: 17324624 DOI: 10.1016/j.hlc.2006.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2006] [Revised: 08/07/2006] [Accepted: 08/16/2006] [Indexed: 11/23/2022]
Abstract
We report a case of spontaneous coronary artery dissection occurring in a young female who had been diagnosed with antiphospholipid syndrome. Coronary angiography revealed extensive dissection in the proximal to mid LAD. She was treated conservatively with an excellent result. Follow-up coronary angiography at two months failed to reveal any evidence of the previous dissection.
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Affiliation(s)
- Rebecca K Reed
- Department of Cardiology, Monash Medical Centre, Melbourne, Vic., Australia.
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24
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Davies JOJ, Hunt BJ. Myocardial infarction in young patients without coronary atherosclerosis: assume primary antiphospholipid syndrome until proved otherwise. Int J Clin Pract 2007; 61:379-84. [PMID: 17313603 DOI: 10.1111/j.1742-1241.2006.01245.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to highlight the need for investigation of antiphospholipid (aPL) antibodies in patients presenting with myocardial infarction (MI) and normal coronary arteries at angiography. We present five patients who were found to have had an MI without evidence of atherosclerosis. All had aPL antibodies and thus fulfilled the diagnosis of antiphospholipid syndrome (APS). Who did not have recurrent events on long-term anticoagulation maintaining an international normalised ratio of 3-4. This study suggests that APS is probably a major cause of MI in those with normal coronary arteries at angiography. It is an important diagnosis to make as they do not require anti-atherosclerotic treatment but appear, from this case series, to do well on high-dose warfarin. Further clinical studies are necessary to look at prevalence and best management in these patients.
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Affiliation(s)
- J O J Davies
- Department of Intensive Care Medicine, St Thomas' Hospital, London, UK
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25
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Kiernan TJ, Rochford M. Postpartum spontaneous coronary artery dissection: An important clinical link with anticardiolipin antibody. Int J Cardiol 2007; 114:E75-6. [PMID: 17070942 DOI: 10.1016/j.ijcard.2006.07.113] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Revised: 07/16/2006] [Accepted: 07/17/2006] [Indexed: 11/22/2022]
Abstract
A 34-year-old woman presented to the Emergency Department with substernal chest pain, 7 days after a normal vaginal delivery. Acute myocardial infarction was diagnosed based on ECG changes and elevated serum troponin levels. Coronary angiography revealed a spontaneous coronary dissection of the left anterior descending (LAD) coronary artery. The patient was managed medically and recovered well clinically with healing of the dissection on repeat angiography 10 days later. Of note the patient had a high titre of anticardiolipin antibody (IgM) detected and this is only the second case described in the literature of an association between spontaneous coronary artery dissection and antiphospholipid antibody syndrome.
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Hammond AS, Bailey PL. Acute Spontaneous Coronary Artery Dissection in the Peripartum Period. J Cardiothorac Vasc Anesth 2006; 20:837-41. [PMID: 17138090 DOI: 10.1053/j.jvca.2005.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Aaron S Hammond
- Department of Anesthesiology, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY 14618, USA
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27
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Garcia Garcia C, Casanovas N, Recasens L, Miranda F, Bruguera J. Spontaneous coronary artery dissection in ergotamine abuse. Int J Cardiol 2006; 118:410-1. [PMID: 17049384 DOI: 10.1016/j.ijcard.2006.07.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 07/12/2006] [Accepted: 07/15/2006] [Indexed: 11/28/2022]
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28
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Manghat NE, Morgan-Hughes GJ, Roobottom CA. Spontaneous coronary artery dissection: appearance and follow-up on multi-detector row CT coronary angiography. Clin Radiol 2005; 60:1120-5. [PMID: 16179173 DOI: 10.1016/j.crad.2005.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2004] [Revised: 05/22/2005] [Accepted: 05/24/2005] [Indexed: 11/16/2022]
Affiliation(s)
- N E Manghat
- Department of Clinical Radiology, Derriford Hospital, Plymouth, UK.
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