This case highlights a condition that is a rare cause of acute myocardial infarction, whose aetiology is poorly understood, and optimal management has not been clearly elucidated. Over 100 cases of spontaneous coronary dissection have been reported in the English literature since the first case was described in 1931.1
It is more common among women and young patients, with women accounting for approximately 73% of cases with a mean age at presentation of 39 years.2
Presentation can involve the full spectrum of acute coronary syndrome manifestations, but sudden cardiac death is the most common.1
Spontaneous coronary artery dissection is characterised by a plane that usually runs in the outer media or between the media and adventitia of the coronary artery, resulting in haemodynamic compromise due to the flap, with blood tracking in it, compressing the lumen.3
The aetiology of this disease is poorly understood. Most affected patients do not have risk factors for coronary heart disease. The risk of spontaneous coronary artery dissection is increased during the peri-partum period with 25–31% of reported cases occurring during this time.1 2
Other predisposing factors include the Marfan and Ehlers–Danlos syndromes and atherosclerosis. Potential triggers of the actual dissecting event include physical exercise, prolonged straining and sneezing.4
These all result in momentary elevation in coronary artery pressure.
As it is infrequent, the evidence for the optimal management of spontaneous coronary artery dissection is limited. The management strategy depends on the clinical situation and the size of the affected artery segment. All suspected cases should undergo urgent coronary angiography. Accepted treatments include percutaneous coronary intervention, coronary artery bypass grafting or conservative medical management. There are no data to support the routine use of antiplatelets, although their use in this case was to prevent occlusion or thrombosis of the implanted coronary stent. Thrombolysis is no longer knowingly used because of its potential to worsen the dissection process.
Spontaneous coronary dissection should always be considered in any young patient, especially women, without classical cardiac risk factors that present with an acute coronary syndrome or cardiac arrest.
Consider spontaneous coronary dissection in:
- Patients presenting with sudden onset ischaemic sounding chest pain.
- Young female patients with no cardiac risk factors and evidence of cardiac ischaemia.
- Pregnant/postpartum patients.