Spontaneous coronary artery rupture presenting as an acute coronary syndrome evolved in pseudoaneurysm and cardiac tamponade: Case report and literature review

Abstract

Spontaneous coronary artery rupture is a rare disorder that may develop early into a sudden death due to the abrupt evolution of the associated cardiac tamponade. In some cases the rupture is contained and a false aneurysm develops with slower evolution of clinical signs. The correct diagnosis of spontaneous coronary artery rupture deserves a high level of suspicion; frequently it may be missed because the time window of its evolution seems to be very short or signs of acute coronary syndrome sometimes can prevail, leading to delays in diagnosis or to misdiagnosis. We report the case of a patient presenting a giant pseudoaneurysm of the right coronary artery due to spontaneous coronary artery rupture without any underlying disease. Moreover we present a review of the few cases in the literature, offering a pathophysiological hypothesis linking the site of rupture and clinical presentation.

Spontaneous coronary artery rupture without a pericardial effusion: a diagnostic challenge

“…Coronary artery rupture usually occurs following PCI, as a result of traumatic dissection or perforation of a coronary artery 2. Other causes include atherosclerosis, coronary artery aneurysm, inflammatory diseases such as Kawasaki's disease, trauma, infection and coronary artery dissection 2–5.…”

“…Occasionally, the rupture is limited to the subepicardial tissue, with an impending false aneurysm 2. Most reported cases of coronary artery rupture have presented with clinical symptoms suggestive of acute coronary syndrome or acute aortic dissection.…”

“…The clinical presentation may differ according to the site of the rupture. Proximal right coronary artery rupture usually presents with a subepicardial haematoma, rather than pericardial haemorrhage, while rupture of the left and distal right coronary arteries commonly manifests as intrapericardial bleeding leading to pericardial tamponade and cardiogenic shock 2. If coronary artery rupture is not detected at a sufficiently early stage, it may progress into life-threatening cardiac tamponade 2…”

“…Coronary rupture can be treated with coated stents 2 3. In the presence of haemopericardium with cardiac tamponade, immediate pericardial drainage or surgical intervention is recommended 2.…”

“…In the English literature, only nine cases of spontaneous coronary artery rupture have been reported 1 2. It is a challenge to diagnose coronary artery rupture in the absence of a pericardial effusion.…”