Multiple spontaneous coronary artery dissections in a middle aged woman: support for an underlying eosinophilic arteritis predisposing to intimal disruption

Abstract

A 43-year-old female received tissue plasminogen activator for an acute antero-apical myocardial infarction. Cardiac catheterization demonstrated three focal dissections involving the left anterior descending and circumflex arteries. She expired unexpectantly after undergoing emergency coronary artery bypass grafting for therapy of an extension of her infarct. To our knowledge, this is the fourth report of multiple spontaneous coronary artery dissections and the second in which tissue plasminogen activator was administered. The histologic findings and their implications are reviewed.

Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment

“…This is well in accordance to the results of our study. There are also reports about dissections of the left main and multivessel dissections [11,[14][15][16][17], which much more frequently occur in women [7]. SCAD in patients with underlying coronary artery disease probably is more frequent than usually thought.…”

“…Disruption and bleeding from vasa vasorum has been suggested as one possible mechanism [11]. An underlying inflammatory process has been discussed by several authors [17,34]. The frequent but inconsistent observation of focal inflammation around the dissected part of the coronary artery supports the hypothesis of an abortive, localized form of vasculitis [17,34].…”

“…SCAD can be associated with use of cocaine, cyclosporin and oral contraceptives [22][23][24]. However, there are several reports of previously healthy young to middleaged people without risk factors or only mild smoking who experienced SCAD [10,11,16,17,[25][26][27][28][29]. Influence of shear- ing stress is thought to be a possible explanation with or without angiographically underlying coronary plaques [29].…”

Eosinophilia and Coronary Artery Vasospasm

“…Kajihara [12] and Omoto [22] showed eosinophilic infiltration around vasa vasorum and nerve fibres, and stimulation of nerve fibres in the adventia is another possible explanation for coronary vasospasm. Eosinophils also cause tissue destruction which predisposes to dissection [27][28][29], aneurysmal dilation [15] and thrombosis [6,17], and later fibrosis of the intima and media of the coronary artery wall [12,23] Multi-focal coronary involvement was common. The high prevalence of asthma and the temporal association between asthma and angina suggest eosinophils can provoke smooth muscle constriction in both coronary arteries and bronchi [31].…”

“…Other findings at coronary angiography or autopsy included aneurysmal coronary artery dilation [15], thrombotic coronary occlusion [6,17] and coronary artery dissection [27][28][29]. In some angiography demonstrated multiple stenoses, but vasodilators were not given, and a diagnosis of vasospasm can not be definitely made [41].…”