Spontaneous coronary artery dissection

Spontaneous coronary artery dissection
Specialty Cardiology Edit this on Wikidata

A spontaneous coronary artery dissection (SCAD) (occasionally coronary artery dissection) is a rare, sometimes fatal traumatic condition, with eighty percent of cases affecting women. One of the coronary arteries develops a tear, causing blood to flow between the layers which forces them apart.[1] Studies of the disease place the mortality rate at around 70%.[2][3]

SCAD is a primary cause of myocardial infarction (MI) in young, fit, healthy women (and some men) with no obvious risk factors. These can often occur during late pregnancy, postpartum and peri-menopausal periods.

Signs and symptoms

The symptoms are often very similar to those of myocardial infarction (heart attack), with the most common being persistent chest pain.[4]

Causes

SCAD

There is evidence to suggest that a major cause of spontaneous coronary artery dissection (SCAD) is related to female hormone levels, as most cases appear to arise in pre-menopausal women, although there is evidence that the condition can have various triggers. Other underlying conditions such as hypertension, recent delivery of a baby, fibromuscular dysplasia and connective-tissue disorders (e.g., Marfan syndrome and Ehlers-Danlos syndrome) may occasionally result in SCAD.[5] There is also a possibility that vigorous exercise can be a trigger. However, many cases have no obvious cause.[6][7]

Pathophysiology

Coronary artery dissection results from a tear in the inner layer of the artery, the tunica intima. This allows blood to penetrate and cause an intramural hematoma in the central layer, the tunica media, and a restriction in the size of the lumen, resulting in reduced blood flow which in turn causes myocardial infarction and can later cause sudden cardiac death.[8][9][10]

Diagnosis

A selective coronary angiogram is the most common method to diagnose the condition, although it is sometimes not recognised until after death.[11][12]Intravascular ultrasound (IVUS) is also used as it is able to more easily differentiate the condition from atherosclerotic disease.[13]

Treatment

Treatment is varied depending upon the nature of the case. In asymptomatic and hemodynamically stable patients it may be appropriate to maintain a conservative strategy, especially if coronarography demonstrates adequate coronary flow: in this situation spontaneous healing is usually the most probable evolution.[14]In severe cases, coronary artery bypass surgery is performed to redirect blood flow around the affected area.[15][16]Drug-eluting stents and thrombolytic drug therapy are less invasive options for less severe cases.[13]However PCI for spontaneous coronary artery dissection is associated with high rates of technical failure, so in many case a strategy of conservative management may be preferable.

Prognosis

The condition is often fatal and is mostly recognized at postmortem examination in young victims of sudden death.[17][18]

Epidemiology

The prevalence of spontaneous coronary dissection varies from about 1% to 4% of all coronarography. About eighty percent of cases are in women, with an average age of around 40.[19][20][21][22]

History

Spontaneous coronary artery dissection (SCAD) was first described in the year 1931, at postmortem examination, in a 42 year old woman.[23]

See also

References

  1. ↑ Robert Slight; Ali Asgar Behranwala; Onyekwelu Nzewi; Rajesh Sivaprakasam; Edward Brackenbury; Pankaj Mankad (2003) "Spontaneous coronary artery dissection: a report of two cases occurring during menstruation" Archived 2010-04-09 at the Wayback Machine. New Zealand Medical Journal]
  2. ↑ DeMaio, SJ Jr; Kinsella, SH; Silverman, ME (1989). "Clinical course and long-term prognosis of spontaneous coronary artery dissection". Am J Cardiol. 64: 471–4. doi:10.1016/0002-9149(89)90423-2. PMID 2773790.
  3. ↑ Khan, NU; Miller, MJ; Babb, JD; Ahmed, S; Saha, PK; Shammas, RL; Macdonald, RG; Movahed, A (2006). "Spontaneous coronary artery dissection". Acute Card Care. 8: 162–71. doi:10.1080/17482940600789190. PMID 17012132.
  4. ↑ "Spontaneous Coronary Artery Dissection Postpartum"
  5. ↑ Dhawan R, Singh G, Fesniak H. (2002) "Spontaneous coronary artery dissection: the clinical spectrum". Angiology
  6. ↑ Mark V. Sherrid; Jennifer Mieres; Allen Mogtader; Naresh Menezes; Gregory Steinberg (1995) "Onset During Exercise of Spontaneous Coronary Artery Dissection and Sudden Death. Occurrence in a Trained Athlete: Case Report and Review of Prior Cases" Chest
  7. ↑ {http://www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/basics/risk-factors/con-20037794}
  8. ↑ Virmani R, Forman MB, Rabinowitz M, McAllister HA (1984) "Coronary artery dissections" Cardiol Clinics
  9. ↑ Kamineni R, Sadhu A, Alpert JS. (2002) "Spontaneous coronary artery dissection: Report of two cases and 50-year review of the literature" Cardiol Rev
  10. ↑ Kamran M, Guptan A, Bogal M (October 2008). "Spontaneous coronary artery dissection: case series and review". J Invasive Cardiol. 20 (10): 553–9. PMID 18830003.
  11. ↑ C. Basso, G. L. Morgagni, G. Thiene (1996) "Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death" BMJ
  12. ↑ Desseigne P, Tabib A, Loire R (July 1992). "[An unusual cause of sudden death: spontaneous dissection of coronary arteries. Apropos of 2 cases]". Arch Mal Coeur Vaiss. 85 (7): 1031–3. PMID 1449336.
  13. 1 2 Intravascular Ultrasound Imaging in the Diagnosis and Treatment: The Future: IVUS-Guided DES Implantation?
  14. ↑ Alfonso F, Paulo M, Lennie V, Dutary J, Bernardo E, Jiménez-Quevedo P, Gonzalo N, Escaned J, Bañuelos C, Pérez-Vizcayno MJ, Hernández R, Macaya C (October 2012). "Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy". JACC Cardiovasc Interv. 5 (10): 1062–70. doi:10.1016/j.jcin.2012.06.014. PMID 23078737.
  15. ↑ MedHelp:Coronary artery dissection treatment
  16. ↑ Tweet MS, Eleid MF, Best PJ, Lennon RJ, Lerman A, Rihal CS, Holmes DR, Hayes SN, Gulati R (December 2014). "Spontaneous coronary artery dissection: revascularization versus conservative therapy". Circ Cardiovasc Interv. 7 (6): 777–86. doi:10.1161/CIRCINTERVENTIONS.114.001659. PMID 25406203.
  17. ↑ Le MQ, Ling FS (August 2007). "Spontaneous dissection of the left main coronary artery treated with percutaneous coronary stenting". J Invasive Cardiol. 19 (8): E218–21. PMID 17712209. Retrieved 2018-03-31.
  18. ↑ Auer J, Punzengruber C, Berent R, Weber T, Lamm G, Hartl P, Eber B (July 2004). "Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound". Heart. 90 (7): e39. doi:10.1136/hrt.2004.035659. PMC 1768303. PMID 15201265.
  19. ↑ Hayes, S (2013), New Insights into This Not-So-Rare Condition
  20. ↑ Vanzetto G, Berger-Coz E, Barone-Rochette G, Chavanon O, Bouvaist H, Hacini R, Blin D, Machecourt J (February 2009). "Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients". Eur J Cardiothorac Surg. 35 (2): 250–4. doi:10.1016/j.ejcts.2008.10.023. PMID 19046896.
  21. ↑ Yip A, Saw J (February 2015). "Spontaneous coronary artery dissection-A review". Cardiovasc Diagn Ther. 5 (1): 37–48. doi:10.3978/j.issn.2223-3652.2015.01.08. PMC 4329168. PMID 25774346.
  22. ↑ Fontanelli A, Olivari Z, La Vecchia L, Basso C, Pagliani L, Marzocchi A, Zonzin P, Vassanelli C, Di Pede F (January 2009). "Spontaneous dissections of coronary arteries and acute coronary syndromes: rationale and design of the DISCOVERY, a multicenter prospective registry with a case-control group". J Cardiovasc Med (Hagerstown). 10 (1): 94–9. PMID 19708230. Retrieved 2018-03-31.
  23. ↑ Pretty HC (18 April 1931). "Dissecting aneurysm of coronary artery in a woman aged 42". British Medical Journal. 1 (3667): 667. doi:10.1136/bmj.1.3667.667.
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