Spontaneous coronary artery dissection: An often unrecognized cause of acute coronary syndrome

Abstract

A 55-year-old woman with hypertension presented with sudden onset of severe pressure-like chest pain that started when she was taking a bath. The pain radiated to her back and was associated with nausea. A 12-lead electrocardiogram (Figure 1) showed ST-segment elevation of more than 2 mm in leads V 2 , V 3 , V 4 , and V 5 , with no reciprocal changes. In view of her ongoing severe chest pain, she was given aspirin and ticagrelor and was taken for emergency cardiac catheterization. Left ventriculography showed hypokinesis in the mid-anterior, distal anterior, apical, and distal inferior chamber walls. Coronary angiography (Figure 2) revealed a long segment of diffuse, smooth narrowing of the mid-left anterior descending coronary artery that did not reverse after administration of intracoronary nitroglycerin. Based on the classic angiographic appearance and the absence of atherosclerotic disease in other coronary arteries, type 2 spontaneous coronary artery dissection (SCAD) was diagnosed. ■ CORONARY ARTERY WALL SEPARATION SCAD is defined as a nontraumatic, noniatrogenic intramural hemorrhage leading to separation of the coronary arterial wall and the formation of a false lumen. The separation can occur between any of the coronary artery wall layers and may or may not involve an intimal tear. The bleeding may result in an intramural hematoma and possible narrowing of the arterial lumen. Depending on the severity of REVIEW

Beyond Atherothrombotic Disease in Acute Coronary Syndrome

“…Properly for dissecting events, a high prevalence of fibromuscular dysplasia, connective diseases, autoimmune diseases, and stress situations has been reported. [7][8][9] SCAD is the cause of 1-4% of all cases of ACS, the vast majority of which appear in women without pregnancy-related conditions. However, when analyzed in pregnant women, SCAD can reach up to 43%, one of the main causes of coronary events in this population.…”

“…Thrombolytic therapy should be avoided. [7][8][9] Medical treatment is based on dual anti-aggregation (monotherapy has been reported in low risk patients) for a minimum of 6 months, with a beta blocker (especially if there is left ventricular dysfunction or arrhythmia control) and a strict control of comorbidities. Severe acute stressful situations should be avoided, and Valsalva maneuver activities should be performed.…”

Unusual Presentation of Post-coital Spontaneous Coronary Artery Dissection

“…Some factors predisposing a patient to SCAD include pregnancy, postpartum state, and the presence of certain arterial diseases such as fibro-muscular dysplasia, connective tissue disorders autoimmune inflammatory systemic disease [ 5 , 6 ]. Mechanical stressors such as heavy weight lifting, excessive isometric exercise, and emotional stressors can exponentially increase the stress forces in the coronary arterial wall leading to dissection [ 2 , 7 , 8 ].…”

Cardiovascular disease in women: A review of spontaneous coronary artery dissection

“…[76] There is limited literature involving CABG in SCAD and is composed primarily of case reports and series. [1,16,66,67,77] Indications for revascularization may include left main coronary artery or severe proximal 2-vessel dissection, active ischemia, hemodynamic instability, cardiogenic shock, or ventricular arrhythmias. [5,62,77] However, judgment should be exercised depending on the clinician's expertise.…”