Case Report

Spontaneous Coronary Artery Dissection

Authors: Gustavo A. Cardenas, MD, Cindy L. Grines, MD, Mark Sheldon, MD, James A. Goldstein, MD

Abstract

A 45-year-old female athlete with no history of cardiovascular disease or coronary risk factors presented with a non–ST-segment elevation myocardial infarction due to spontaneous right coronary artery dissection. She was treated medically with resolution of her symptoms. Repeat angiography due to recurrent exertional chest discomfort showed TIMI-3 flow and no evidence of dissection. Intravascular ultrasound documented discrete areas of resolving hematoma, but no dissection flap or impingement of the lumen >30%. A coronary computed tomography 6 months later revealed absence of any vascular abnormalities. This rare but potentially lethal condition should be considered in the differential diagnosis of young patients with chest pain, myocardial infarction, or sudden cardiac death, especially if it involves women either in the peripartum period or those using oral contraceptives, or patients without evidence of coronary atherosclerosis or traditional cardiovascular risk factors.


Key Points


* Spontaneous coronary artery dissection (SCAD) should be considered in the differential diagnosis of young patients with chest pain, myocardial infarction, or sudden cardiac death, especially women either in the peripartum period or using oral contraceptives, or patients without evidence of coronary atherosclerosis or traditional cardiovascular risk factors.


* Diagnosis is generally done with standard coronary angiography, occasionally with the assistance of intravascular ultrasound. Multidetector row computed coronary angiography may also facilitate the diagnosis of SCAD, especially in the emergency setting, but experience with this technique is still very limited.


* Treatment option (percutaneous coronary intervention with stenting, conservative medical management, or coronary artery bypass graft) is determined by the location of dissection, number of vessels involved, compromise of coronary blood flow, extent of jeopardized myocardium, and hemodynamic status.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Kamineni R, Sadhu A, Alpert JS. Spontaneous coronary artery dissection: report of two cases and a 50-year review of the literature. Cardiol Rev 2002;10:279–284.
 
2. DeMaio SJ Jr, Kinsella SH, Silverman ME. Clinical course and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989;64:471–474.
 
3. Dhawan R, Singh G, Fesniak H. Spontaneous coronary artery dissection: the clinical spectrum. Angiology 2002;53:89–93.
 
4. Maeder M, Ammann P, Angehrn W, et al. Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Cardiol 2005;101:363–369.
 
5. Zampieri P, Aggio S, Roncon L, et al. Follow up after spontaneous coronary artery dissection: a report of five cases. Heart 1996;75:206–209.
 
6. Catanese V, Venot P, Lemesle F, et al. Myocardial infarction by spontaneous dissection of coronary arteries in a subject with type IV Ehlers-Danlos syndrome. Presse Med 1995;24:1345–1347.
 
7. Aldoboni AH, Hamza EA, Majdi K, et al. Spontaneous dissection of coronary artery treated by primary stenting as the first presentation of systemic lupus erythematosus. J Invasive Cardiol 2002;14:694–696.
 
8. Kerwin TC, Ruggie N, Klein LW. Spontaneous coronary artery dissection following low-intensity blunt chest trauma: a case report and review of current treatment options. J Invasive Cardiol 2002;14:679–681.
 
9. Lie JT, Berg KK. Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction. Hum Pathol 1987;18:654–656.
 
10. Steinhauer JR, Caulfield JB. Spontaneous coronary artery dissection associated with cocaine use: a case report and brief review. Cardiovasc Pathol 2001;10:141–145.
 
11. Almeda FQ, Barkatullah S, Kavinsky CJ. Spontaneous coronary artery dissection. Clin Cardiol 2004;27:377–380.
 
12. Greenblatt JM, Kochar GS, Albornoz MA. Multivessel spontaneous coronary artery dissection in a patient with severe systolic hypertension: a possible association. A case report. Angiology 1999;50:509–513.
 
13. Schifferdecker B, Pacifico L, Ramsaran EK, et al. Spontaneous coronary artery dissection associated with sexual intercourse. Am J Cardiol 2004;93:1323–1324.
 
14. Jorgensen MB, Aharonian V, Mansukhani P, et al. Spontaneous coronary dissection: a cluster of cases with this rare finding. Am Heart J 1994;127:1382–1387.
 
15. Mulvany NJ, Ranson DL, Pilbeam MC. Isolated dissection of the coronary artery: a postmortem study of seven cases. Pathology 2001;33:307–311.
 
16. Robinowitz M, Virmani R, McAllister HAJ. Spontaneous coronary artery dissection and eosinophilic inflammation: a cause and effect relationship? Am J Med 1982;72:923–928.
 
17. Bac DJ, Lotgering FK, Verkaaik AP, et al. Spontaneous coronary artery dissection during pregnancy and post partum. Eur Heart J 1995;16:136–138.
 
18. Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death. Heart 1996;75:451–454.
 
19. Hering D, Piper C, Hohmann C, et al. Prospective study of the incidence, pathogenesis and therapy of spontaneous, by coronary angiography diagnosed coronary artery dissection. Z Kardiol 1998;87:961–970.
 
20. Maehara A, Mintz GS, Castagna MT, et al. Intravascular ultrasound assessment of spontaneous coronary artery dissection. Am J Cardiol 2002;89:466–468.
 
21. Manghat NE, Morgan-Hughes GJ, Roobottom CA. Spontaneous coronary artery dissection: appearance and follow-up on multi-detector row CT coronary angiography. Clin Radiol 2005;60:1120–1125.
 
22. Sarmento-Leite R, Machado PR, Garcia SL. Spontaneous coronary artery dissection: stent it or wait for healing? Heart 2003;89:164.
 
23. Hong MK, Satler LF, Mintz GS, et al. Treatment of spontaneous coronary artery dissection with intracoronary stenting. Am Heart J 1996;132:200–202.
 
24. Bocek P. Idiopathic spontaneous coronary artery dissection and drug-eluting stents. Int J Cardiol 2006;112:367.
 
25. Zupan I, Noc M, Trinkaus D, et al. Double vessel extension of spontaneous left main coronary artery dissection in young women treated with thrombolytics. Catheter Cardiovasc Interv 2001;52:226–230.
 
26. Koller PT, Cliffe CM, Ridley DJ. Immunosuppressive therapy for peripartum-type spontaneous coronary artery dissection: case report and review. Clin Cardiol 1998;21:40–46.