Spontaneous coronary artery dissection – rare but challenging

Biljana Putniković; Ivan Ilić; Miloš Panić; Aleksandar Aleksić; Radosav VIdaković; Aleksandar N. Nešković

doi:10.2298/2408

Biljana Putniković Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Ivan Ilić Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Miloš Panić Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Aleksandar Aleksić Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Radosav VIdaković Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Aleksandar N. Nešković Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

DOI: https://doi.org/10.2298/2408

Keywords: acute coronary syndrome, dissection, coronary angiography, diagnosis, treatment outcome,

Abstract

Introduction. Spontaneous coronary artery dissection (SCAD) is a rare cause of the acute coronary syndrome. It occurs mostly in patients without atherosclerotic coronary artery disease, carrying fairly high early mortality rate. The treatment of choice (interventional, surgical, or medical) for this serious condition is not well-defined. Case report. A 41-year old woman was admitted to our hospital after the initial, unsuccessful thrombolytic treatment for anterior myocardial infarction administered in a local hospital without cardiac catheterization laboratory. Immediate coronary angiography showed spontaneous coronary dissection of the left main and left anterior descending coronary artery. Follow-up coronary angiography performed 5 days after, showed extension of the dissection into the circumflex artery. Because of preserved coronary blood flow (thrombolysis in myocardial infarction – TIMI II-III), and the absence of angina and heart failure symptoms, the patient was treated medicaly with dual antiplatelet therapy, a low molecular weight heparin, a beta-blocker, an angiotensin-converting enzyme (ACE) inhibitor and a statin. The patient was discharged after 12 days. On follow-up visits after 6 months and 2 years, the patient was asymptomatic, and coronary angiography showed the persistence of dissection with preserved coronary blood flow. Conclusion. Immediate coronary angiography is necessary to assess the coronary anatomy and extent of SCAD. In patients free of angina or heart failure symptoms, with preserved coronary artery blood flow, medical therapy is a viable option. Further evidence is needed to clarify optimal treatment strategy for this rare cause of acute coronary syndrome.

Author Biographies

Biljana Putniković, Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Department of Cardiology, Chief

Ivan Ilić, Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Department of Cardiology, Cardiac catheterization laboratory, interventional cardiologist

Miloš Panić, Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Department of Cardiology, Coronary Care unit, Chief

Aleksandar Aleksić, Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Department of Cardiology, Cardiac catheterization laboratory, interventional cardiologist

Radosav VIdaković, Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Department of Cardiology, cardiologist

Aleksandar N. Nešković, Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Department of Cardiology, Cardiac catheterization laboratory,Chief

References

Verma PK, Sandhu MS, Mittal BR, Aggarwal N, Kumar A, Mayank M, et al. Large spontaneous coronary artery dissections-a study of three cases, literature review, and possible therapeutic strategies. Angiology 2004; 55(3): 309−18.

Rohit MK, Garg PK, Hariram V, Gupta A, Grover A. Idiopathic spontaneous coronary artery dissection presenting as acute myocardial infarction in a young boy. Indian Heart J 2008; 60(4) :346−8.

Vrints CJ. Spontaneous coronary artery dissection. Heart 2010; 96(10): 801−8.

Tanis W, Stella PR, Kirkels JH, Pijlman AH, Peters RH, de Man FH. Spontaneous coronary artery dissection: current insights and therapy. Neth Heart J 2008; 16(10): 344−9.

Rosengarten JA, Dana A. Recurrent spontaneous coronary artery dissection: acute management and literature review. Eur Heart J Acute Cardiovasc Care 2012; 1(1): 53−6.

Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Sponta-neous coronary artery dissection: A Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009; 74(5): 710−7.

Vanzetto G, Berger Coz E, Barone-Rochette G, Chavanon O, Bouvaist H, Hacini R, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dis-section: results from a database of 11,605 patients. Eur J Car-diothorac Surg 2009; 35(2): 250−4.

Coronary artery angiographic changes after PTCA. In Manual of operations NHLBI. PTCA Registry 1985; 6: 9.

Pretty HC. Dissecting aneurysm of coronary artery in a woman aged 42: Rupture. Br Med J 1931; 1: 667.

Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atheroscle-rotic patients: Report of nine cases with review of the perti-nent literature. Eur J Cardiothorac Surg 2001; 20(3): 573−6.

Hering D, Piper C, Hohmann C, Schultheiss HP, Horstkotte D. Pro-spective study of the incidence, pathogenesis and therapy of spontaneous, by coronary angiography diagnosed coronary artery dissection. Z Kardiol 1998; 87(12): 961−70.

Jorgensen MB, Aharonian V, Mansukhani P, Mahrer PR. Sponta-neous coronary dissection: A cluster of cases with this rare finding. Am Heart J 1994; 127(5): 1382−7.

Pasalodos PJ, Vazquez GN, Perez AL, Vazquez RJ, Castro BA. Spontaneous coronary artery dissection. Cathet Cardiovasc Diagn 1994; 32(1): 27−32.

Zampieri P, Aggio S, Roncon L, Rinuncini M, Canova C, Zanazzi G, et al. Follow up after spontaneous coronary artery dissection: a report of five cases. Heart 1996; 75(2): 206−9.

Robinowitz M, Virmani R, Mcallister HJ. Spontaneous coronary artery dissection and eosinophilic inflammation: A cause and effect relationship. Am J Med 1982; 72(6): 923−8.

Barger AC, Beeuwkes R, Lainey LL, Silverman KJ. Hypothesis: vasa vasorum and neovascularization of human coronary arteries. A possible role in the pathophysiology of atherosclerosis. N Engl J Med 1984; 310(3): 175−7.

Thayer JO, Healy RW, Maggs PR. Spontaneous coronary artery dissection. Ann Thorac Surg 1987; 44(1): 97−102.

Shankarappa RK, Panneerselvam A, Dwarakaprasad R, Karur S, Krishnanaik GB, Nanjappa MC. Spontaneous asymptomatic coronary artery dissection in a young man. J Cardiol 2009; 54(3): 499−502.

Leclercq F, Messner P, Carabasse D, Lucke N, Rivalland F, Grolleau R. Successful thrombolysis treatment of a spontaneous left main coronary artery dissection without subsequent surgery. Eur Heart J 1996; 17(2): 320−1.

Buys EM, Suttorp MJ, Morshuis WJ, Plokker HW. Extension of a spontaneous coronary artery dissection due to thrombolytic therapy. Cathet Cardiovasc Diagn 1994; 33(2): 157−60.

Zupan I, Noc M, Trinkaus D, Popovic M. Double vessel extension of spontaneous left main coronary artery dissection in young women treated with thrombolytics. Catheter Cardiovasc Interv 2001;52(2):226-30.

Keon WJ, Koshal A, Boyd WD, Laramee L, Farrell E, Walley VM. Survival after spontaneous primary left main coronary artery dissection. Acute surgical intervention with the Jarvik 7-70 artificial heart. J Cardiovasc Surg (Torino) 1989; 30(5): 786−9.

Curiel P, Spinelli G, Petrella A, Gori A, De Maria R, Bonacina E, Gronda E. Postpartum coronary artery dissection followed by heart transplantation. Am J Obstet Gynecol 1990; 163(2): 538−9.

Thompson EA, Ferraris S, Gress T, Ferraris V. Gender differences and predictors of mortality in spontaneous coronary artery dissection: A review of reported cases. J Invasive Cardiol 2005; 17(1): 59−61.

Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012; 126(5): 579−88.

Alfonso F. Spontaneous coronary artery dissection: new in-sights from the tip of the iceberg? Circulation 2012; 126(6): 667−70.