Large spontaneous coronary artery dissections-a study of three cases, literature review, and possible therapeutic strategies

Spontaneous Coronary Artery Dissection in Young Patients: A Case Series and Review of Current Management Algorithm

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized non-atherosclerotic cause of acute coronary syndrome. Common risk factors for SCAD are coronary atherosclerosis, female gender, peripartum period, systemic inflammatory conditions, and connective tissue disorders. It manifests as myocardial ischemia and infarction, arrhythmia, and sudden cardiac death. We present a case series of two young men and one young female with SCAD who had chest pain and were diagnosed with SCAD-associated ST-elevation myocardial infarction. Its diagnosis requires a high degree of clinical suspicion and its management is guided by the patient's clinical condition and the characteristics of the lesions.

Snake in right coronary artery—Extensive spontaneous coronary artery dissection in a young male

We report an interesting case of a young man who revealed extensive spontaneous dissection of the RCA in diagnostic angiography. It was surprising that despite an extensive dissection, the patient remained hemodynamically stable on medical management throughout the procedure and during the post‐procedure hospital stay.

Interventional Dilemma in a Young Woman With Spontaneous Coronary Artery Dissection Who Presented With High-Risk Non-ST-Elevation Myocardial Infarction (NSTEMI) Progressing to ST-Elevation Myocardial Infarction (STEMI)

Spontaneous coronary artery dissection (SCAD) is an infrequent presentation of acute myocardial infarction in young women and denotes the non-atherosclerotic separation of the coronary artery wall. Precipitating causes include fibromuscular dysplasia, postpartum hormonal changes, multiparity, connective tissue diseases like Marfan syndrome, autoimmune conditions, and hormonal therapy. It is often underdiagnosed due to a low index of suspicion based on age and gender bias as well as knowledge about different angiographic variants in SCAD. Intracoronary imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is used for patients where coronary angiography fails to secure a diagnosis to increase the diagnostic yield. The mainstay of stable SCAD is conservative management. However, there are no definitive guidelines due to limited clinical experience. Treatment involving percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), fibrinolytic therapy, and mechanical hemodynamic support should be individualized depending upon clinical presentation, type, and extent of dissection, hemodynamic instability, critical anatomy involvement, and the extent of ischemic myocardium. We are presenting a case of a young female who presented with non-ST-elevation myocardial infarction (NSTEMI) that progressed to ST-elevation myocardial infarction (STEMI). A coronary angiogram showed a tortuous left anterior descending artery (LAD) with a distal 100% occlusion due to SCAD. PCI was attempted but the guidewire could not be navigated intraluminally past the occlusion. CABG was not pursued due to the distal location of the occlusion and lack of visualization of the distal vessel. Our case provides a useful learning opportunity for physicians who may come across similar clinical presentations. In patients with high-risk features of SCAD who are deemed inoperable, timely and appropriate medical management may be a useful alternative for PCI/CABG and the recurrence rates of SCAD are very low.

Recurrent Spontaneous Coronary Artery Dissection in 4 Vascular Territories

Spontaneous coronary artery dissection, a rare cause of acute coronary syndrome, is due to nonatherosclerotic coronary events and is probably underrecognized as a cause of myocardial infarction. The condition typically affects premenopausal women who are otherwise healthy. Among more than 1,200 reported cases, recurrent dissection has been described 63 times, and only 3 reports have documented multiple episodes of dissection involving different vascular territories. We present the case of a woman in her 30s who, over a 9-year period, presented 4 times with coronary dissection in different vascular territories. She was first treated conservatively, then with stents, and ultimately by means of coronary artery bypass grafting. In addition to this case, we discuss this rare condition and its management.

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.

Spontaneous Coronary Artery Dissection: One Disease, Variable Presentations, and Different Management Approaches

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. It occurs predominantly among younger females, typically in the absence of atherosclerotic coronary artery disease. Presentations vary greatly and this condition can be fatal. Given its rarity, there are no management guidelines. We present six patients with SCAD with different presentations and treatment approaches as examples in our literature review. Two patients presented with ST elevation myocardial infarction (STEMI), two with non-STEMI (NSTEMI), and two with cardiac arrest. Patients were treated according to the presentation, clinical stability, and extension and distribution of the dissection. Four patients underwent emergent percutaneous coronary intervention (PCI) and one was clinically stable and treated medically initially and underwent an elective PCI after 4 weeks when coronary angiogram showed persistent dissection. Another patient was treated medically as he was hemodynamically stable and the dissection affected a small branch. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used for diagnosis confirmation as well as during and after PCI to assure good stent apposition. All patients had excellent outcome. SCAD is a rare cause of acute coronary syndrome and a high index of suspicion is crucial for early diagnosis. In patients with early presentation, limited disease, and ongoing symptoms, emergent cardiac catheterization with PCI has excellent outcome. However, in stable patients, medical management and elective PCI in few weeks if the dissection persists is a more reasonable approach. IVUS and OCT are invaluable especially in ambiguous cases.

Sudden cardiac death from structural heart diseases in adults: imaging findings with cardiovascular computed tomography and magnetic resonance

Sudden cardiac death (SCD) is defined as the unexpected natural death from a cardiac cause within an hour of the onset of symptoms in the absence of any other cause. Although such a rapid course of death is mainly attributed to a cardiac arrhythmia, identification of structural heart disease by cardiovascular computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging is important to predict the long-term risk of SCD. In adults, SCD most commonly results from coronary artery diseases, coronary artery anomalies, inherited cardiomyopathies, valvular heart diseases, myocarditis, and aortic dissection with coronary artery involvement or acute aortic regurgitation. This review describes the CCT and CMR findings of structural heart diseases related to SCD, which are essential for radiologists to diagnose or predict.

Spontaneous coronary artery dissection: Case series from two institutions with literature review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Consequently, its presentation and optimal treatment are yet to be clearly defined. In the current literature, all case series report less than 50 patients, most of whom are either young peripartum women or women who have used oral contraceptives over long periods. All information in this study was compiled by the database service from two hospitals, the first one between 2003 and 2012 and the second one between 2007 and 2012, to include the clinical characteristics, angiography. and treatment approaches in the study population. The study population consisted in four women (50%) and four men (50%) whose ages ranged between 28 and 57 years. Two women had a history of oral contraceptive use and three women presented during peripartum. None of the patients had traditional cardiovascular risk factors or previous heart disease. In 88% of the cases, the principal diagnoses were non-ST segment elevation myocardial infarction and unstable angina. All patients underwent emergency coronary angiography and percutaneous coronary intervention. Half of them were treated with drug-eluting stents and the other half with bare metal stents. The most frequent type of dissection was NIHBL Type E, and the right coronary artery was the most frequently compromised. SCAD is a rare cause of ACS; however, its identification has improved due to the availability of angiography and new complementary techniques. Regarding treatment, PCI seems effective with adequate long-term results.

Spontaneous Coronary Artery Dissection and Hemodynamic Instability: Can Emergent PCI Be Life Saving? Report of Two Cases and Literature Review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. It occurs predominantly among younger females and typically in the absence of atherosclerotic coronary artery disease. It is associated with peripartum period, connective tissue disorders, vasculitides, and extreme exertion. Presentations vary greatly, and this condition can be fatal. Given its rarity, there are no guidelines for management of SCAD. We present the cases of two female patients, with no coronary artery disease risk factors or recent pregnancy, who were presented with non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI), respectively, secondary to SCAD. Both had excellent outcome after emergent percutaneous intervention. Our first patient was presented with NSTEMI with ongoing chest pain and dynamic electrocardiogram (ECG). Emergent left heart catheterization was significant for first obtuse marginal (OM1) dissection, confirmed by optical coherence tomography. Percutaneous coronary intervention (PCI) with two bare metal stents was performed with resolution of symptoms and ECG changes. The second patient is known to have syndrome, presented with STEMI and emergent coronary angiography showed left anterior descending dissection with intramural hematoma confirmed by intravascular ultrasound and treated with a drug-eluting stent with resolution of symptoms and ST changes. Her hospital course was complicated by post-myocardial infarction pericarditis that was improved with colchicine. Both the patients were observed in the coronary care unit for 24 hours. Both remained asymptomatic at 6-month follow-up. SCAD is a rare cause of acute coronary syndrome. In patients with early presentation, limited disease, and ongoing symptoms, emergent cardiac catheterization with percutaneous intervention has excellent outcome. More studies are needed to establish evidence-based management guidelines.

Spontaneous coronary artery dissection: a rare cause of acute coronary syndrome

We present a case of a 71-year-old man, with a history of hypertension and dyslipidaemia, who presented with typical cardiac chest pain and palpitations of 2 h duration. The examination revealed irregular pulse of 138 bpm, blood pressure 115/75 mm Hg, variable first and normal second heart sounds. The lungs were clear to auscultation. The ECG showed atrial fibrillation with a rapid ventricular rate. His heart rate was controlled with β blockers and the acute coronary syndrome treatment protocol was initiated. His baseline blood reports were within normal limits and two serial troponin I tests were negative. Coronary angiogram showed dissection in the left coronary system extending into the branch vessels and 30-40% stenosis in the right coronary artery. The patient underwent coronary artery bypass graft as an emergent case. He suffered a mild stroke postsurgery with complete functional recovery. He is being followed up in the clinic and has performed well.

Spontaneous coronary artery dissection: case report and review of literature

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome or sudden cardiac death. SCAD has most frequently been described as presenting as an acute coronary syndrome in females during the peripartum period. It may also be associated with autoimmune and collagen vascular diseases, Marfan's syndrome, chest trauma, and intense physical exercise. The most common presentation of SCAD is the acute onset of severe chest pain associated with autonomic symptoms. This condition has a high mortality rate if not identified and treated promptly. Here, we present a case of SCAD presenting with stroke, followed by a brief review.

Recurrent spontaneous coronary artery dissection: A case report and review of the literature

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. Recurrent spontaneous dissection is even more rare. A case of recurrent coronary artery dissection is reported and the literature is reviewed.

The utility of intravascular ultrasound for the diagnosis and management of spontaneous coronary artery dissection in a middle-aged woman with acute inferior myocardial infarction

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute myocardial ischemia and is associated with various pathophysiologies, such as pregnancy, postpartum, and collagen diseases. It is frequently fatal and most cases are diagnosed at autopsy. Therefore, the early diagnosis of SCAD and initiation of treatment may be life saving. In this report, we describe a case of SCAD of right coronary artery, possibly triggered by transient high blood pressure, with no apparent atherosclerotic involvement detected by intravascular ultrasound (IVUS) and successfully treated with stent implantation. The IVUS helped us to confirm the diagnosis, navigate the guidewire into the true lumen, and understand the mechanism for the appearance of a lotus root formation.

Spontaneous coronary artery dissection in a young man - case report

A 31 year old man with a 17-year-history of drug abuse (heroine and cannabis) was admitted with recurrent chest pain over a period of about three weeks. Chest discomfort severely worsened during the 5 hours before hospital admission. Electrocardiography revealed poor R-wave progression and non specific repolarization abnormalities. Echocardiography showed extensive left ventricular anterior and apical wall motion abnormalities and a ventricular thrombus located at the apex of the left ventricle was present. Subsequently, a diagnosis of acute coronary syndrome was made. Coronary angiography revealed spontaneous coronary artery dissection of the left anterior descending (LAD) artery with Thrombolysis In Myocardial Infarction (TIMI) flow 2 to 3. We managed the patient conservatively. The clinical course was uneventful and repeated angiography on day 4 demonstrated spontaneous healing of large parts of the dissection with TIMI 3 flow in the LAD.

A Spontaneous Coronary Artery Dissection Case Noticed during a Primary PCI

Spontaneous coronary dissections (SCAD) can be asymptomatic or can manifest itself as any of the clinical spectrum of the ischemic heart disease. In this report, we present a 65 year old man presented with myocardial infarction in whom coronary angiography a nonocclusive SCAD was noticed in addition to a very late stent thrombosis and make a brief overview of the treatment for SCAD.

Spontaneous coronary artery dissection of all major coronary arteries

Spontaneous coronary artery dissection is a rare cause of myocardial infarction and sudden cardiac death. A 32-year-old man presented with effort angina. He had a positive treadmill exercise electrocardiogram test, and coronary angiography showed that he had dissection of all major coronary vessels. The left anterior descending coronary artery was completely blocked, probably secondary to dissection and subsequent occlusion. He was advised to undergo coronary artery bypass surgery, to which he did not agree; instead, he was treated by medication and followed up.

Recurrent spontaneous coronary artery dissection with transient left ventricular systolic dysfunction

Spontaneous coronary artery dissection (SCAD) is a potentially life-threatening entity with a variety of clinical presentations. We report a patient who presented with chest pain and angiographic evidence of coronary dissection. Due to the rapid resolution of symptoms and benign-appearing nature of the dissection, no intervention was pursued and the patient was maintained on medical therapy. She represented 2 days later with substernal chest pain, dynamic EKG changes, positive cardiac biomarkers and a transient depression of her left ventricular function.