Recurrent acute coronary syndrome in a patient with right coronary artery ectasia: a case report

Abstract

Background Coronary artery ectasia is characterized by an abnormal dilatation of the coronary arteries. Coronary artery ectasia is observed in 3–8% of patients undergoing coronary angiography and sometimes leads to acute coronary syndrome regardless of the presence or absence of coronary stenosis or atrial fibrillation. Case presentation A 61-year-old Indonesian man presented with typical angina that began 1 week before admission and had worsened 3 hours prior to admission. Accompanying symptoms included dyspnea, nausea, and sweating. He was hemodynamically stable and had a history of tobacco smoking and dyslipidemia. An electrocardiogram showed ST-segment depression and T inversion. Laboratory results showed an international normalized ratio of 1.28. Dual antiplatelet therapy was administered along with fondaparinux, and symptoms were alleviated. Coronary angiography showed an ectatic and turbulent mid-distal right coronary artery and slow flow at the first presentation. There was a patent stent in the proximal-mid left anterior descending coronary artery. This patient had previously presented with recurrent acute coronary syndrome and received two coronary stents for the stenotic vessels. Discussion He had right coronary artery ectasia and experienced recurrent acute coronary syndrome. He received dual antiplatelet therapy along with warfarin after stenting of his left anterior descending coronary artery. However, he presented with unstable angina pectoris 7 months before the latest admission and at the latest admission despite a patent stent and no other significant obstructive lesion. The unstable angina pectoris might have been caused by slow flow, microvascular angina caused by small thrombi and/or vasospasm, or epicardial thrombosis at the ectatic coronary artery that dissolved after anticoagulation therapy prior to coronary angiography. Anticoagulant therapy may have a greater benefit than antiplatelet therapy in this patient due to the turbulence and stasis of blood in the ectatic vessel, although coexisting coronary conditions mandated antiplatelet therapy. His international normalized ratio was suboptimal and needed to be improved. Conclusion Coronary ectasia may play a role in recurrent acute coronary syndrome, and administration of an anticoagulant to prevent acute coronary syndrome in this patient was in accordance with the varying hemodynamic property of coronary artery ectasia.

Is Anticoagulant Necessary in Patients with Coronary Artery Ectasia Presenting with Acute Coronary Syndrome? A Systematic Review of Case Reports

“…9,11,14 This became more evident in a case by Damay et al who recorded four times ACS recurrence in which all of the stenotic lesion had been stented, before achieving 6 months' event free after optimal anticoagulation by warfarin. 17 Possible explanation for this finding is that stasis and slow-flow in the ectatic coronary artery is responsible for the clot formation rather than plaque rupture that usually occurs due to atherosclerotic vessels and role of anticoagulant is greater than antiplatelet in such condition. Several procoagulant factors are hypothesized to be increased in CAE, such as the serine proteases, these enzymes act as a catalytic factor in the coagulation cascade.…”

The Simultaneity of Coronary Artery Ectasia and Intracranial Arterial Dolichoectasia: A Case Report and Literature Review

“…2019;10(11):328-332 attributable to atherosclerosis, and 10-20% are associated with inflammatory or connective tissue disease. CAE is diagnosed in approximately 3-8% of patients undergoing coronary angiography, and these patients sometimes present with acute coronary syndrome [3,6]. On the other hand, IADE is typically found accidentally or when related complications arise.…”

“…Approximately 20-30% of CAE presentations are congenital, 50% are attributable to atherosclerosis, and 10-20% are associated with inflammatory or connective tissue disease. CAE is diagnosed in approximately 3-8% of patients undergoing coronary angiography, and these patients sometimes present with acute coronary syndrome [ 3 , 6 ].…”

“…The role of nitrates or calcium channel blockers for angina remains controversial [ 11 ]. With the strong association between CAE and atherosclerosis, guideline-directed medical therapy for risk factors such as hypertension, diabetes, and hyperlipidemia should be considered [ 6 ]; medications such as angiotensin-converting enzyme (ACE) inhibitors and statins may be useful in disrupting disease progression [ 3 ].…”

Commentary: For unusual cases, preparation is key

“…Lifelong antiplatelet therapy and anticoagulation have both been described in several case series. 2 , 3 , 4 Our concern with this approach in a woman of child-bearing age is the need for lifelong anticoagulation, and perhaps antiplatelet therapy would be more appropriate in this patient.…”