Spontaneous coronary artery dissection and its association with takotsubo syndrome: Novel insights from a tertiary center registry

Abstract

Background Spontaneous coronary artery dissection (SCAD) is a relatively rare cause of acute coronary syndrome historically thought to primarily affect young, healthy women. The lack of multicenter collaborative research efforts has made it challenging to identify the precise etiology and pathological mechanisms underlying SCAD. However, there are many similarities in the patient demographics, clinical presentations, and predisposing stressors between SCAD and takotsubo syndrome (TTS). Objectives The aim of this observational study was to examine the coronary and left ventriculographic features of patients with angiographically confirmed SCAD and determine the prevalence of concomitant TTS. Methods In this observational study, patients with angiographically confirmed SCAD were identified from the Massachusetts General Hospital SCAD registry. The coronary angiograms with simultaneous left ventriculograms (LVG) were carefully analyzed by an independent and blinded angiographic core laboratory. Results From our analysis of patients with SCAD who also underwent a LVG at time of coronary angiography, we identified a high prevalence of SCAD and concomitant TTS. Conclusions Therefore, we present TTS as a plausible mechanistic etiology for SCAD in some patients. In light of this finding as well as the many similarities between SCAD and TTS, clinicians should be vigilant about the potential concomitant presence of these two entities. Additional future investigations further exploring the clinical implications of the association between SCAD and TTS are warranted.

COVID-19: A double threat to takotsubo cardiomyopathy and spontaneous coronary artery dissection?

“…COVID‐19 testing prior to cardiac catheterization or imaging in suspected cases with unknown COVID-19 status may be considered. Based on the study by Duran et al, approximately 55.8% of the angiographically-confirmed SCAD patients who underwent left ventriculography were found to have a concomitant TTC [21] . The high prevalence of coexistence suggests the need of a high index of clinical suspicion and diagnostic modalities (such as angiography, left ventriculography, or echocardiography) when encountering SCAD or TTC.…”

“…In the setting of TTC, vigorous contraction of the left ventricular base in conjunction with adjacent dyskinetic segments could form a prerequisite anatomical substrate for the causation of SCAD. The coronary dissection plane may develop as a result of excessive movement of the epicardial vessels and increased shear stress on the vessel wall at the hinge point between the hyperdynamic and akinetic myocardium [21] . It has also been speculated that the coronary arteries traversing the anterior or anterolateral wall would be more vulnerable to dissection as this region marks the transition point of the hyperdynamic basal segment and the remaining hypokinetic left ventricular segments [21] .…”

“…The coronary dissection plane may develop as a result of excessive movement of the epicardial vessels and increased shear stress on the vessel wall at the hinge point between the hyperdynamic and akinetic myocardium [21] . It has also been speculated that the coronary arteries traversing the anterior or anterolateral wall would be more vulnerable to dissection as this region marks the transition point of the hyperdynamic basal segment and the remaining hypokinetic left ventricular segments [21] . In addition, the vulnerable coronary substrate may occur as a consequence of coronary vasospasm due to catecholamine excess in TTC.…”

Tearing into Takotsubo

“…While the current study reports an interesting overlap of TTS and SCAD, it is difficult to apply to a larger patient population given the limited size of the study. The authors' SCAD registry spans the time course of almost 3 years with 43 patients, which is an impressive sample given the inherent infrequency of the disease and paucity of reported SCAD events, though still small when trying to parse associations and predictors.…”

“…Duran et al should be commended for their contribution to the knowledge of both SCAD and TTS and their thought‐provoking retrospective study. The current study aims to look at angiographically confirmed SCAD cases to determine the prevalence of concomitant TTS . It is a retrospective analysis of 43 patients, 39 of whom are female, enrolled in the SCAD registry at the Massachusetts General Hospital between July 2013 and February 2016 with angiographically confirmed SCAD with a simultaneous left ventriculogram.…”