Ruptured cerebral aneurysm and acute coronary artery dissection in the setting of multivascular fibromuscular dysplasia: a case report

Fibromuscular Dysplasia Implicated in Spontaneous Coronary Artery Dissection (SCAD): A Case Report of Chest Pain in Young Women

Spontaneous coronary artery dissection (SCAD) is a well-recognized cause of acute coronary syndrome (ACS) which can lead to myocardial infarction and sudden death. Unlike typical atherosclerosis, SCAD operates through distinct pathophysiology, affecting both individuals with and without conventional cardiovascular risk factors. We present a case of a young female presented with retrosternal chest pain radiating to the left arm, mimicking ACS symptoms with mildly elevated troponin levels, and slightly reduced left ventricular ejection fraction (45%). Subsequent evaluation using coronary angiography unveiled a Type 2A SCAD. A comprehensive computed tomography angiography (CTA) of her entire body revealed findings suggestive of fibromuscular dysplasia (FMD) affecting multiple arteries in different sites. Our case entailed the successful management of a young female patient with SCAD stemming from FMD.

Pregnancy-Associated Spontaneous Coronary Acute Dissection as a Cause of Sudden Cardiac Death-Autopsy Findings and Literature Review: Is COVID-19 Related?

Sudden cardiac death (SCD) is the leading cause of mortality globally (violent or non-violent), with few to no feasible remedies. The etiopathogenesis of SCD involves a complex and multilayered substrate in which dynamic factors interact with a preexistent cardiovascular pathology, which is often undiagnosed and untreated, leading to the rapid development of cardiac rhythm disorders and cardiac arrest. Cardiovascular disease is a rare but emerging factor in maternal mortality that can be justified by an upward trend in the mean age of pregnant individuals. Spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic and non-iatrogenic separation of the coronary arterial wall by intramural hemorrhage with or without an intimal tear. The resulting intramural hematoma compresses the coronary arteries, reducing blood flow and causing myocardial ischemia. SCAD continues to be misdiagnosed, underdiagnosed, and managed as an atherosclerotic acute coronary syndrome, which may harm patients with SCAD. The latest research shows that individuals who have or have had coronavirus disease 2019 (COVID-19) may also present coagulation abnormalities, so infection with COVID-19 during pregnancy can increase this hypercoagulable condition, thus increasing the risk of SCAD and SCD. This present study reports two cases over 35 years, one being infected with SARS-COV2 one month before the event and the other being tested positive during admission, both asymptomatic, who were declared healthy on periodic clinical evaluations, with pregnancies over 35 weeks, with normal fetal development, which suddenly caused chest pain, dyspnea, and loss of consciousness, required emergency c-sections, and died suddenly after they were performed. In both cases, the cause of death was SCAD on the anterior-descending artery. In both cases, emergency percutaneous coronary intervention was performed. The second part of the study represents a literature overview of SCAD during COVID-19. In addition to pregnancy hormonal changes, other potential hormone-mediated SCAD triggers are still under discussion.

Spontaneous Coronary Artery Dissection: Review of Possible Pathophysiological Risk Factors

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that typically affects the younger and healthier female population without the typical ACS risk factors such as hypertension, diabetes, or hyperlipidemia. The clinical presentation of SCAD can be diverse and the diagnosis is typically by coronary angiography but also can require advanced imaging such as intravascular ultrasound or optical coherence tomography. Past studies have shown the atypical patient characteristics of SCAD patients among ACS patients. The main challenge is that the exact pathophysiology of SCAD is unknown. Potential pathophysiological risk factors are discussed including fibromuscular dysplasia, other arteriopathies, pregnancy and female sex hormone changes, migraines, inflammatory conditions, and stress. The current understanding of these risk factors along with potential pathophysiological mechanisms are discussed. There still remain many areas of additional investigation in understanding this rare cause of ACS.

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.

Cardiac rehabilitation following coronary artery dissection: recommendations and patient considerations

INTRODUCTION

: Cardiac rehabilitation (CR) is a multidisciplinary intervention for secondary prevention, improving functional capacity, enhancing quality of life, and improving psychosocial wellbeing in broad range of cardiovascular disease. It has been well studied over a number of years and is a Class I recommendation in multiple guidelines. However, there is a paucity of data regarding the usefulness of CR in patients with spontaneous coronary artery dissection (SCAD).

AREAS COVERED

: This narrative review aims to give an overview of the evidence underpinning CR as well as the pathophysiological mechanisms of SCAD and how they relate to exercise and shear stress. Furthermore, the evidence of the usefulness of CR in the SCAD population will be reviewed.

EXPERT OPINION

: Traditional CR programs are safe and effective in SCAD cohorts, however SCAD specific CR (SCAD-CR) has significant benefits including reductions in MACE. The principles of SCAD-CR should be applied to any CR for SCAD patients for optimal outcomes and minimization of harm.

Coronary Angiographic Manifestations and Outcomes in Spontaneous Coronary Artery Dissection Patients With and Without Fibromuscular Dysplasia

BACKGROUND

Fibromuscular dysplasia (FMD) is widely recognized as an important predisposing condition for spontaneous coronary artery dissection (SCAD). However, it remains unclear in SCAD patients with coexistent extracoronary FMD whether SCAD can be attributed to coronary FMD.

METHODS

We retrospectively analyzed consecutive patients enrolled in our Vancouver SCAD registries between September 2009 and October 2019 who were screened for extracoronary FMD. We reviewed coronary angiograms for manifestations of coronary FMD that were previously described (ie, irregular stenosis, smooth stenosis, dilatation/ectasia, and severe tortuosity). Outcome of interest was major adverse cardiovascular event (MACE).

RESULTS

We included 346 SCAD patients, of these, 250 (72.3%) had extracoronary FMD. Patients with FMD were older (54.6 ± 9.5 vs 51.7 ± 9.8 years) and more likely to have prior history of myocardial infarction (7.2% vs 1.0%, P = 0.047) and stroke (4.4% vs 0%, P = 0.081) compared with non-FMD patients. On coronary angiography, severe tortuosity was more prevalent in patients with extracoronary FMD (58.4% vs 36.5%, P < 0.001). Rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were numerically higher in patients with extracoronary FMD, but differences were not significantly different. The rate of MACE at median follow-up of 807 (interquartile range, 392-1096) days was not different between groups (19.6% vs 15.6%; non-FMD as a reference: hazard ratio 1.44; 95% confidence interval, 0.76-2.71, P = 0.261).

CONCLUSION

SCAD patients with extracoronary FMD were more likely to have coronary FMD manifestations on angiogram, especially severely tortuous vessels, compared with those without extracoronary FMD, with similar clinical outcomes. This may suggest that SCAD can occur at sites of pre-existent subclinical coronary FMD.

Spontaneous coronary artery dissection: presentation and management options

Coronary artery dissection is a serious, life-threatening heart condition. It can occur spontaneously or due to traumatic or iatrogenic causes. Spontaneous coronary artery dissection (SCAD) is often misdiagnosed as most patients present with symptoms resembling those of an acute coronary syndrome. Clinical sequelae of SCAD include debilitating morbidities such as myocardial infarction, myocardial ischaemia, sudden cardiac death, ventricular arrhythmias amongst many other myocardial ischaemia associated complications. There are two main methods of managing patients with SCAD; conservative management with medical therapy or revascularisation by percutaneous coronary intervention or coronary artery bypass grafting.

Spontaneous Coronary Artery Dissection: An Unusual Cause of ST-Elevation Myocardial Infarction in Young Males

Spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-iatrogenic, and non-atherosclerotic coronary artery disorder that manifests clinically as an acute coronary syndrome (ACS), arrhythmia, or sudden cardiac death (SCD). It is a rare cause of ACS (1.7-4%) and SCD (0.5%), more commonly in women than men. It is rarely reported in males. We report a case of acute ST-elevation myocardial infarction (STEMI) due to SCAD in a 44-year-old healthy male.

Chromosome 1q21.2 and additional loci influence risk of spontaneous coronary artery dissection and myocardial infarction

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction (MI), typically in young women. We undertook a genome-wide association study of SCAD (N_cases = 270/N_controls = 5,263) and identified and replicated an association of rs12740679 at chromosome 1q21.2 (P_{discovery+replication} = 2.19 × 10⁻¹², OR = 1.8) influencing ADAMTSL4 expression. Meta-analysis of discovery and replication samples identified associations with P < 5 × 10⁻⁸ at chromosome 6p24.1 in PHACTR1, chromosome 12q13.3 in LRP1, and in females-only, at chromosome 21q22.11 near LINC00310. A polygenic risk score for SCAD was associated with (1) higher risk of SCAD in individuals with fibromuscular dysplasia (P = 0.021, OR = 1.82 [95% CI: 1.09–3.02]) and (2) lower risk of atherosclerotic coronary artery disease and MI in the UK Biobank (P = 1.28 × 10⁻¹⁷, HR = 0.91 [95% CI :0.89–0.93], for MI) and Million Veteran Program (P = 9.33 × 10⁻³⁶, OR = 0.95 [95% CI: 0.94–0.96], for CAD; P = 3.35 × 10⁻⁶, OR = 0.96 [95% CI: 0.95–0.98] for MI). Here we report that SCAD-related MI and atherosclerotic MI exist at opposite ends of a genetic risk spectrum, inciting MI with disparate underlying vascular biology.

Spontaneous coronary artery dissection (SCAD) is a cause of myocardial infarction Here, the authors present a genome-wide association study of SCAD, finding an association at 1q21.2 which potentially affects expression of ADAMTSL4.

Post-traumatic aneurysmal rupture involving the circle of Willis affected by fibromuscular dysplasia. A case report and systematic review

The fatal rupture of a saccular aneurysm at the junction between the left anterior cerebral artery and anterior communicating artery affected by fibromuscular dysplasia (FMD) is a rare condition. Here is reported the case of a subject involved in a road traffic accident a few minutes before the death, which opened the debate on the real cause of death in a forensic setting. By autopsy, the examination of the brain revealed subarachnoid haemorrhage with flooding of the ventricles due to the breached saccular aneurysm of the junction between the left anterior cerebral artery and anterior communicating artery, in FMD mainly affecting the circle of Willis arteries. A spontaneous aneurysmal rupture was excluded on the basis of probabilistic analysis, in the presence of alternative hypotheses that could explain the facts. The passenger's delayed loss of consciousness may be explained as much by a hypertension-linked rupture of the aneurysm triggered by the emotional stress experienced, as by the traumatic shaking/impact of the aneurysm against the bony skull structures, in a subject predisposed to aneurysm frailty due to FMD. Overall, the concausal role of both the road traffic accident, typified by high kinetic energy, and the presence of a pre-existing aneurysmatic weakness due to FMD is fully recognized. The identification of anatomical variants, jointly with uncommon diseases at the examination of the brain base arteries in any case of isolated basal subarachnoid haemorrhage, may avoid wrong legal consequences even when the cause of death seems to be obviously of simple traumatic origin.

First international consensus on the diagnosis and management of fibromuscular dysplasia

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

[Spontaneous Coronary Artery Dissection]

During several recent decades spontaneous coronary artery dissection (SCAD) has been known as one of causes of development of acute coronary syndrome (ACS). It has been assumed that this condition is extremely rarely met and is associated with pregnancy and postpartum period. The use in clinical practice of high sensitivity troponin, coronary angiography (CAG) in early period of ACS, in conjunction with the growing awareness of doctors about this pathology led to a revision of the viewse on prevalence of the disease. At present SCAD is considered as one of the causes of ACS in young and middle-aged women. In this review we present results of studies of pathogenesis, diagnostics, and treatment of SCAD, describe various angiographic types of this disease, and discuss problems of choice of optimal strategy of management of patients with SCAD.

First International Consensus on the diagnosis and management of fibromuscular dysplasia

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group ‘Hypertension and the Kidney’ of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

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.

Contemporary Review on Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is gaining recognition as an important cause of myocardial infarction, especially in young women. There has been a surge in the diagnosis of SCAD in recent years, presumably due to an increased use of coronary angiography, and the clinical availability and application of high-resolution intracoronary imaging. The improved recognition and diagnosis, together with increased publications and attention through social media, have considerably raised awareness of this condition, which was once believed to be very rare. Recent publications of moderate to large contemporary case series have helped elucidate the early natural history, presenting characteristics (clinical and angiographic), underlying etiology, management, and cardiovascular outcomes with this condition, thus providing observations and important clinical insights of value to clinicians managing this challenging and perplexing patient cohort. The aim of our review is to provide a comprehensive contemporary update of SCAD to aid health care professionals in managing these patients in both the acute and chronic settings.

Angiographic and Intracoronary Manifestations of Coronary Fibromuscular Dysplasia

BACKGROUND

We previously described a strong association between fibromuscular dysplasia (FMD) and spontaneous coronary artery dissection. Angiographic manifestations of coronary FMD aside from dissection were considered rare. However, we observed several coronary FMD angiographic abnormalities with corresponding optical coherence tomography abnormalities.

METHODS AND RESULTS

Baseline demographics and imaging of patients with suspected coronary FMD at Vancouver General Hospital were reviewed. Presence of multifocal (string-of-beads) extracoronary FMD was confirmed by 2 specialists. In these patients, coronary angiographic findings (excluding dissected segments) were reviewed and classified by 2 experienced angiographers for irregular stenosis, that is, stenosis with irregular borders in a focal or diffuse pattern with/without systolic accentuation; smooth stenosis, diffuse or focal; segmental dilatation/ectasia; and tortuosity. Optical coherence tomography was performed in a subset of patients. Of 32 patients with extracoronary FMD and suspected coronary involvement, 28 were women (88%), and their mean age was 59.4±9.9 years. Nineteen presented with myocardial infarction (13 caused by spontaneous coronary artery dissection), and 13 had stable symptoms. The observed coronary angiographic abnormalities included tortuosity in all cases (91% were moderate to severe), irregular stenosis in 59%, smooth stenosis in 19%, and segmental dilatation/ectasia in 56%. Fifteen patients had optical coherence tomography of the abnormal segments showing abnormalities, including multiple areas of patchy or diffuse intimal, medial or adventitial abnormalities with thickening/accumulation of varied reflectivities, macrophage infiltration, loss/duplication of elastic membranes, and cavitation.

CONCLUSIONS

This is the first case series describing findings suggestive of angiographic and intracoronary manifestations of coronary FMD. Future studies should prospectively review these features in patients with extracoronary FMD.

Optical Coherence Tomography in the Diagnosis and Management of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent condition that has been underdiagnosed and misdiagnosed. The use of intracoronary imaging with intravascular ultrasound or optical coherence tomography enables the accurate diagnosis of this challenging condition. Diagnostic and management algorithms have been proposed to improve the diagnosis and therapeutic stratification of SCAD. Optical coherence tomography has superior spatial resolution than intravascular ultrasound, and is instrumental in the diagnosis of SCAD cases where angiographic findings are ambiguous for confirming SCAD. Understanding the role and appropriate and careful use of this technology is expected to improve the diagnosis of SCAD, and also improve outcomes with percutaneous coronary intervention, when clinically indicated.

Sudden death due to coronary artery dissection associated with fibromuscular dysplasia revealed by postmortem selective computed tomography coronary angiography: A case report

We present an autopsy case of sudden death due to coronary artery dissection associated with fibromuscular dysplasia (FMD) in a young female patient. Postmortem selective coronary artery computed tomography (CT) angiography revealed dissections of the left anterior descending and left circumflex arteries. These findings were confirmed by subsequent autopsy. Histopathological examination revealed coronary artery FMD, which is considered a risk factor for dissection. To the best of our knowledge, this is the first postmortem radiology-pathology correlation of coronary artery dissection associated with FMD.

Spontaneous coronary artery dissection-A review

Spontaneous coronary artery dissection (SCAD) is an infrequent and often missed diagnosis among patients presenting with acute coronary syndrome (ACS). Unfortunately, SCAD can result in significant morbidities such as myocardial ischemia and infarction, ventricular arrhythmias and sudden cardiac death. Lack of angiographic recognition from clinicians is a major factor of under-diagnosis. With the advent of new imaging modalities, particularly with intracoronary imaging, there has been improved diagnosis of SCAD. The aim of this paper is to review the epidemiology, etiology, presentation, diagnosis and management of SCAD.

A case of type A aortic dissection with underlying fibromuscular dysplasia

Fibromuscular dysplasia is a rare, non-atherosclerotic non-inflammatory vascular disease that most commonly involves the renal arteries and carotid arteries, but has been described in nearly every vascular bed in the body. Complications of fibromuscular dysplasia include aneurysms and vascular dissection. We present a rare case of fibromuscular dysplasia involving the aorta, complicated by type A aortic dissection.