Spontaneous coronary artery dissection: a report of three cases and review of the literature

Abstract

We describe the clinical course of three patients who developed spontaneous coronary artery dissection. All patients were young women, one 9 weeks pregnant. All presented with chest pain; one died suddenly proving refractory to resuscitation, another developed unstable angina culminating in myocardial infarction, cardiogenic shock and death, and the third patient underwent coronary artery bypass grafting following diagnosis of a spontaneous coronary dissection of the left anterior descending artery at angiography. Pathological findings in the two fatal cases are reported. This condition, although rare, is a prominent cause of ischaemic coronary events in young women, when it is frequently associated with pregnancy or the puerperium. Most patients die suddenly, but a clinical spectrum is seen including stable and unstable angina, myocardial infarction and cardiogenic shock. The left anterior descending artery is most frequently affected. The classical histological finding is that of a large haematoma occupying the outer third of the media resulting in complete compression of the true lumen. The cause of spontaneous dissection remains unclear but theories of aetiology include a medial eosinophilic angiitis, pregnancy-induced degeneration of collagen in conjunction with the stresses of parturition, and rupture of the vasal vasorum. The diagnosis must be considered when a patient presents with a suggestive clinical profile. Urgent angiography should be undertaken to establish the diagnosis and consideration given to the need for coronary artery bypass grafting, which has been successfully employed in a number of patients. The uneventful long-term survival of cases treated conservatively has been reported.

How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

“…A gender difference has moreover been reported with left anterior descendent more frequently involved in females, while right coronary artery in males [45,46] (Figure 2). …”

Pathophysiology and treatment of arterial dissection and stroke

“…In this article, the authors outline the possible pathophysiology of arterial dissection causing stroke, how it is currently diagnosed and treated and how further large trials are required to improve the prognosis of this condition. 4,5 with neurological deficit following dissection present with a transient ischaemic attack as opposed to completed stroke. Neurological deficits include cranial nerve palsy, Horner's syndrome or tinnitus.…”

“…They can be spontaneous or can occur as a result of a trauma as simple as turning the neck. 4,5 However, the differentiation between spontaneous and traumatic dissections is ar tificial because of a continuum between both forms. It is better to define conditions as predisposing factors rather than true causes as the pathophysiology of stroke and dissection is relatively unknown (see Table 1).…”

Postpartum spontaneous coronary artery dissection

“…[1,2] Multiparity and twin pregnancies, which can result in hemodynamic stress from pregnancy-related volume overloading, and endothelial dysfunction are considered to be the main risk factors associated with PSCAD. [3,4] In the acute phase, an urgent coronary angiography and an intravascular ultrasound are recommended for the diagnosis and its treatment. [5] Medical or conservative therapy, percutaneous coronary intervention (PCI), or CABG have been suggested.…”