indian heart journal 68 (2016) 184–185
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Research Letter
Spontaneous left main coronary artery dissection article info
abstract
Keywords:
Spontaneous coronary artery dissection (SCAD) is a very rare clinical condition. Physiopa-
Spontaneous coronary dissection
thology of SCAD is still mostly unclear. Clinical presentation of SCAD ranges from atypical
Left main coronary artery
symptoms to sudden cardiac death. The diagnosis of dissection is generally made by using
Smoking
conventional coronary angiography. Invasive or conservative treatment is reasonable. # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Spontaneous coronary artery dissection (SCAD) is a very rare clinical condition with an incidence of 0.1–1% in patients referred for coronary angiography and more than 80% of the patients are women and the mean age is 43 years.1 Most cases are related with peripartum period but SCAD is also associated with atherosclerosis. SCAD can also be associated with connective tissue disease, cocaine use, vigorous exercise, SLE, and oral contraceptive use.2,3 However, the underlying reason of the dissection cannot be identified in most cases. A 32-year-old female patient with a history of active smoking was admitted to our department with exertional dyspnea and atypical chest pain. She had been smoking for 10 years. She had no history of hypertension, diabetes mellitus, hyperlipidemia, or any remarkable history of medical condition. At the admission, her blood pressure was 90/60 mmHg and heart rate was 77 beats/min. Electrocardiogram (ECG) revealed normal sinus rhythm. Transthoracic echocardiography showed normal left ventricular systolic function. Treadmill stress ECG revealed 1–2 mm ST segment depression over leads II, III, and aVF and V5–V6 in accordance with positive stress test. Coronary angiography performed and demonstrated spontaneous dissections of the left main coronary artery and left anterior descending artery (Fig. 1). Since there was TIMI 3 flow in the distal segments of the affected coronaries, it was decided to follow up the patient closely without performing any intervention. Clinical presentation of SCAD depends on the extent and the severity of the dissection, and ranges from atypical symptoms to sudden cardiac death. Whereas left coronary artery dissection is more common in women, dissections of the RCA occur more frequently in men.4 Overall, LAD is
affected in 70–75% of cases, RCA in 20% of cases, Cx in 5%, and LMCA < 1% of cases.5 The diagnosis of dissection is generally made by using conventional coronary angiography with multiple views. If there is any doubt in diagnosis, IVUS can be performed. Primary PCI remains the reperfusion strategy of choice; however, in small and medium-sized arteries with TIMI-3 flow, conservative treatment may be preferable like in our case. Thrombolytic therapy is discouraged because it may result in further propagation of the dissection due to progression of the intramural hematoma. With conservative measures, coronary artery dissections have even shown complete angiographic resolution after a year. In case of atherosclerosis, aggressive measures should be taken to stabilize atherosclerotic plaques. These measures include aggressive lipid lowering by statins, bblockade, antihypertensive therapy, and antiplatelet therapy. However, when there are no signs of atherosclerosis in the coronary arteries, statins are not indicated, although bblockers and platelet inhibitors do need to be continued after discharge.2 Prognosis is better if underlying cause of the dissection is atherosclerosis. Overall mortality tends to be better, if the patient survives the acute episode. It has been reported that 50% of patients with SCAD developed a recurrent dissection within two months.2 Therefore, monitoring patients with SCAD outpatient is recommended. In conclusion, we report a case of SCAD of the left main and left anterior descending coronary arteries. The patient was an active smoker without any other risk factor for atherosclerosis. We believe that smoking is an important contributor pathogenesis of SCAD.
indian heart journal 68 (2016) 184–185
185
Fig. 1 – Left coronary angiography demonstrated dissection of the left main and left anterior descending coronary arteries.
Conflicts of interest The authors have none to declare.
references
1. Alfonso F, Bastante T, Cuesta J, Rodríguez D, Benedicto A, Rivero F. Spontaneous coronary artery dissection: novel insights on diagnosis and management. Cardiovasc Diagn Ther. 2015;5:133–140. 2. Uribe CE, Ramirez-Barrera JD, Rubio C, et al. Spontaneous coronary artery dissection: case series from two institutions with literature review. Anatol J Cardiol. 2015;15:409–415. 3. Alfonso F, Bastante T, Rivero F, et al. Spontaneous coronary artery dissection. Circ J. 2014;78:2099–2110. 4. Kearney P, Singh H, Hutter J, Khan S, Lee G, Lucey J. Spontaneous coronary artery dissection: a report of three cases and review of the literature. Postgrad Med J. 1993;69:940–945. 5. Virmani R, Forman MB, Rabinowitz M, McAllister Jr HA. Coronary artery dissections. Cardiol Clin. 1984;4:633–646.
Alptug Tokatli* Golcuk Military Hospital, Department of Cardiology, Kocaeli, Turkey Ersan Tatli Yusuf Can Turker Pabuccu Sakarya University, Department of Cardiology, Sakarya, Turkey *Corresponding author E-mail address: [email protected] (A. Tokatli) Available online 11 January 2016
http://dx.doi.org/10.1016/j.ihj.2015.11.009 0019-4832/ # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Research Letter
Spontaneous left main coronary artery dissection article info
abstract
Keywords:
Spontaneous coronary artery dissection (SCAD) is a very rare clinical condition. Physiopa-
Spontaneous coronary dissection
thology of SCAD is still mostly unclear. Clinical presentation of SCAD ranges from atypical
Left main coronary artery
symptoms to sudden cardiac death. The diagnosis of dissection is generally made by using
Smoking
conventional coronary angiography. Invasive or conservative treatment is reasonable. # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Spontaneous coronary artery dissection (SCAD) is a very rare clinical condition with an incidence of 0.1–1% in patients referred for coronary angiography and more than 80% of the patients are women and the mean age is 43 years.1 Most cases are related with peripartum period but SCAD is also associated with atherosclerosis. SCAD can also be associated with connective tissue disease, cocaine use, vigorous exercise, SLE, and oral contraceptive use.2,3 However, the underlying reason of the dissection cannot be identified in most cases. A 32-year-old female patient with a history of active smoking was admitted to our department with exertional dyspnea and atypical chest pain. She had been smoking for 10 years. She had no history of hypertension, diabetes mellitus, hyperlipidemia, or any remarkable history of medical condition. At the admission, her blood pressure was 90/60 mmHg and heart rate was 77 beats/min. Electrocardiogram (ECG) revealed normal sinus rhythm. Transthoracic echocardiography showed normal left ventricular systolic function. Treadmill stress ECG revealed 1–2 mm ST segment depression over leads II, III, and aVF and V5–V6 in accordance with positive stress test. Coronary angiography performed and demonstrated spontaneous dissections of the left main coronary artery and left anterior descending artery (Fig. 1). Since there was TIMI 3 flow in the distal segments of the affected coronaries, it was decided to follow up the patient closely without performing any intervention. Clinical presentation of SCAD depends on the extent and the severity of the dissection, and ranges from atypical symptoms to sudden cardiac death. Whereas left coronary artery dissection is more common in women, dissections of the RCA occur more frequently in men.4 Overall, LAD is
affected in 70–75% of cases, RCA in 20% of cases, Cx in 5%, and LMCA < 1% of cases.5 The diagnosis of dissection is generally made by using conventional coronary angiography with multiple views. If there is any doubt in diagnosis, IVUS can be performed. Primary PCI remains the reperfusion strategy of choice; however, in small and medium-sized arteries with TIMI-3 flow, conservative treatment may be preferable like in our case. Thrombolytic therapy is discouraged because it may result in further propagation of the dissection due to progression of the intramural hematoma. With conservative measures, coronary artery dissections have even shown complete angiographic resolution after a year. In case of atherosclerosis, aggressive measures should be taken to stabilize atherosclerotic plaques. These measures include aggressive lipid lowering by statins, bblockade, antihypertensive therapy, and antiplatelet therapy. However, when there are no signs of atherosclerosis in the coronary arteries, statins are not indicated, although bblockers and platelet inhibitors do need to be continued after discharge.2 Prognosis is better if underlying cause of the dissection is atherosclerosis. Overall mortality tends to be better, if the patient survives the acute episode. It has been reported that 50% of patients with SCAD developed a recurrent dissection within two months.2 Therefore, monitoring patients with SCAD outpatient is recommended. In conclusion, we report a case of SCAD of the left main and left anterior descending coronary arteries. The patient was an active smoker without any other risk factor for atherosclerosis. We believe that smoking is an important contributor pathogenesis of SCAD.
indian heart journal 68 (2016) 184–185
185
Fig. 1 – Left coronary angiography demonstrated dissection of the left main and left anterior descending coronary arteries.
Conflicts of interest The authors have none to declare.
references
1. Alfonso F, Bastante T, Cuesta J, Rodríguez D, Benedicto A, Rivero F. Spontaneous coronary artery dissection: novel insights on diagnosis and management. Cardiovasc Diagn Ther. 2015;5:133–140. 2. Uribe CE, Ramirez-Barrera JD, Rubio C, et al. Spontaneous coronary artery dissection: case series from two institutions with literature review. Anatol J Cardiol. 2015;15:409–415. 3. Alfonso F, Bastante T, Rivero F, et al. Spontaneous coronary artery dissection. Circ J. 2014;78:2099–2110. 4. Kearney P, Singh H, Hutter J, Khan S, Lee G, Lucey J. Spontaneous coronary artery dissection: a report of three cases and review of the literature. Postgrad Med J. 1993;69:940–945. 5. Virmani R, Forman MB, Rabinowitz M, McAllister Jr HA. Coronary artery dissections. Cardiol Clin. 1984;4:633–646.
Alptug Tokatli* Golcuk Military Hospital, Department of Cardiology, Kocaeli, Turkey Ersan Tatli Yusuf Can Turker Pabuccu Sakarya University, Department of Cardiology, Sakarya, Turkey *Corresponding author E-mail address: [email protected] (A. Tokatli) Available online 11 January 2016
http://dx.doi.org/10.1016/j.ihj.2015.11.009 0019-4832/ # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
