Spontaneous coronary artery dissection is a rare but important cause of acute coronary syndrome. It can cause unstable angina, acute myocardial infarction, and sudden death. The condition commonly affects young females with about one-third of the cases occurring during pregnancy and the peripartum period. The diagnosis may occasionally be overlooked as the patients are often young and have no risk factors for coronary artery disease.
Here we report the case of a 29-year-old African American woman who presented with acute coronary syndrome due to spontaneous dissection of the first obtuse marginal branch of the left circumflex coronary artery at three weeks post-partum and recovered requiring only medical management, possibly by longitudinal distribution of the intramural hematoma leading to good distal flow.
Spontaneous coronary artery dissection should be suspected in all young multiparous females presenting with chest pain in the peripartum period even in the absence of risk factors. Urgent diagnosis by angiography is required. It is recommended that treatment should be tailored to meet individual circumstances. Patients who present with single-vessel disease and hemodynamic stability, and who receive medical treatment with anticoagulation, nitrates and a beta-blocker, should experience good results.
Coronary artery dissection is a rare but well-described cause for myocardial infarction during the post-partum period. Dissection of multiple coronary arteries is even less frequent. Here we present a case of recurrent post-partum coronary artery dissections. This unusual presentation poses unique problems for management. A 35 year-old female, gravida 3 para 2, presented with myocardial infarction 9 weeks and 3 days post-partum. Cardiac catheterization demonstrated left anterior descending (LAD) dissection but an otherwise normal coronary anatomy. The lesion was treated with four everolimus eluting stents. Initially the patient made an unremarkable recovery until ventricular fibrillation arrest occurred on the following day. Unsynchronized cardioversion restored a normal sinus rhythm and repeat catheterization revealed new right coronary artery (RCA) dissection. A wire was passed distally, but it was unclear whether this was through the true or false lumen and no stents could be placed. However, improvement of distal RCA perfusion was noted on angiogram. Despite failure of interventional therapy the patient was therefore treated conservatively. Early operation after myocardial infarction has a significantly elevated risk of mortality and the initial dissection had occurred within 24 hours. This strategy proved successful as follow-up transthoracic echocardiography after four months demonstrated a preserved left ventricular ejection fraction of 55-60% without regional wall motion abnormalities. The patient remained asymptomatic from a cardiac point of view.
Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome and sudden cardiac death. We report an unusual case of multi vessel spontaneous coronary artery dissection in an elderly woman with successful medical management.
A 65 year-old woman with hypertension and Parkinson's disease presented with sudden onset severe chest pain. Electrocardiogram showed ischemic ST-segment elevation in inferior and lateral leads. Urgent cardiac catheterization revealed focal dissections in four small caliber coronary arteries in right and left coronary systems including right posterior decending, posterolateral, obtuse marginal and septal arteries. Angiography demonstrated no significant atherosclerotic coronary artery disease. The patient was medically managed with Eptifibatide, Aspirin, Clopidogrel and β blocker since dissected vessels were not technically suitable for percutaneous coronary intervention. Antiparkinson medications were held as a potential cause of dissection. She responded well to medical management.
Coronary dissection should be considered in all patients with an acute coronary syndrome. Medical management is an effective therapeutic option for the patient with small vessel dissections.
Spontaneous coronary artery dissection and vertebral artery dissection are rare, life-threatening conditions. The pathophysiology of spontaneous coronary artery dissection during the peripartum period is poorly understood. We present a case of spontaneous multivessel dissection in a 32-year-old postpartum woman who presented with neck and chest pain. The patient's coronary and vertebral artery dissections were diagnosed with use of multiple imaging methods, and dissection of the internal mammary artery was discovered during surgery. The patient underwent successful coronary artery bypass grafting and remained asymptomatic 2 years later. To our knowledge, this is the first report of simultaneous coronary, vertebral, and internal mammary artery dissection in a postpartum woman. Early recognition and treatment is crucial, given the high mortality rate associated with spontaneous dissection.
Acute coronary syndrome/etiology; coronary artery bypass; postpartum period; pregnancy complications, cardiovascular/diagnosis; rupture, spontaneous/diagnosis/etiology/surgery; treatment outcome; vertebral artery dissection/epidemiology/surgery/ultrasonography
Spontaneous coronary artery dissection is an important yet rare cause of acute coronary syndrome. The available literature shows a higher risk factor for women, notably during pregnancy and puerperium. The incidence in postmenopausal women is exceedingly rare, and is more commonly seen in association with concurrent predisposing factors.
We illustrate an extremely rare case of a 62-year-old post-menopausal woman presenting with an acute myocardial infarction secondary to spontaneous dissection of the left anterior descending artery. Subsequent investigations did not reveal the presence of any co-morbidities.
To the best of our knowledge, our patient is one of the oldest documented cases of spontaneous coronary artery dissection on record, and is notable for having no known underlying risk factors for development of spontaneous coronary artery dissection.
Given the paucity of literature on spontaneous coronary artery dissection, particularly in postmenopausal women, we believe this case will provide further insight into the clinical presentation and management of this rare entity.
A 62-year-old previously healthy postmenopausal Hispanic woman presented with chest pain and was found to have an ST elevation myocardial infarction. Cardiac catheterization revealed a dissection in her left anterior descending artery. Revascularization was deferred; our patient received appropriate medical management and remained asymptomatic. A full panel of tests was done to exclude underlying connective tissue disorders and vasculitis. On subsequent follow-up, our patient continued to do well and all work-up was reported as negative.
We describe the varied presentation and subsequent management of a case of spontaneous coronary artery dissection and highlight the importance of considering spontaneous coronary artery dissection as a differential diagnosis even in older, postmenopausal women.
The consequences of a delay in diagnosis and appropriate management are associated with a high mortality and morbidity; hence we believe that reporting all cases of spontaneous coronary artery dissection, particularly in postmenopausal women, will add invaluable information to the limited literature on this rare condition.
Spontaneous coronary artery dissection is a rare cause of acute ischemic coronary events and sudden cardiac death. It usually occurs in young women without traditional risk factors for coronary artery disease during pregnancy or postpartum period. However, it has also been reported in patients with atherosclerotic coronary disease. We present a case of spontaneous right coronary artery dissection in a 48-year male with recent myocardial infarction and previous percutaneous coronary intervention.
Coronary artery dissection; atherosclerosis.
Spontaneous coronary artery dissection is a rather rare cause of myocardial infarction, chest pain, and sudden death. Since the condition was first described in 1931, fewer than 200 cases have been reported in the medical literature. There are currently no known direct causes of this condition, although some correlations have been noted. Many patients are women in the peripartum period or of childbearing age, with few or no risk factors for coronary artery disease. Other associations include contraceptive use and connective-tissue disorders, Ehlers-Danlos and Marfan syndromes, and polyarteritis nodosa. Most of the reported dissections have occurred in the left anterior descending coronary artery. Herein, we report the case of a 36-year-old woman who presented at our institution with an acute ST-elevation myocardial infarction secondary to a spontaneous dissection of the right coronary artery. Thrombectomy and stenting resolved the occlusion of the artery, and the patient was discharged from the hospital on medical therapy. We discuss the pathophysiology, presentation, and treatment of this rare and often fatal condition.
Coronary vessels/pathology; dissection; female; rupture, spontaneous/complications/physiopathology
Spontaneous coronary artery dissection is an unusual cause of acute myocardial ischemia. The natural history of spontaneous coronary artery dissection that persists on angiography after the acute event has not been well characterized. A case of a 36-year-old man who presented with monomorphic ventricular tachycardia 12 years following a myocardial infarction that occurred during his last course of bleomycin-etoposidecisplatin therapy for testicular cancer is reported. On further investigation, coronary angiography revealed a long chronic dissection of the right coronary artery. The patient was successfully treated with medical management and insertion of an implantable cardioverter defibrillator. The case also highlights the increased cardiovascular morbidity in testicular cancer survivors and evokes the possibility of mechanisms of myocardial ischemia other than atherosclerotic disease in these young patients.
Cisplatin; Coronary artery dissection; Myocardial infarction; Ventricular tachycardia
Although spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, it should be considered during the evaluation of patients who have chest pain. Coronary vasospasm can lead to spontaneous dissection. The dopamine agonist cabergoline is known to cause digital vasospasm. Herein, we report a case of spontaneous right coronary artery dissection in a 43-year-old woman who was taking cabergoline as therapy for prolactinoma. To our knowledge, this is the first report of an apparent relationship between cabergoline therapy and spontaneous coronary artery dissection. The possible association of cabergoline with coronary artery spasm and dissection should be considered in patients who present with chest pain while taking this medication.
Acute coronary syndrome/diagnosis/etiology/therapy; cabergoline/adverse effects; coronary vasospasm/chemically induced; dopamine agonists/adverse effects; rupture, spontaneous/diagnosis/etiology; substance-related disorders/complications
Spontaneous coronary artery dissection, which causes acute coronary syndrome and can result in sudden death, is rare; but its true incidence is underestimated, since most patients die suddenly, without diagnosis. The aim of this study was to show the importance of prompt diagnosis and treatment.
In reviewing the records of 5,000 consecutive patients who underwent coronary angiography between January 2001 and August 2006, we found 6 cases of spontaneous coronary artery dissection (an incidence rate of 0.12%). Five patients presented with left main coronary artery dissection and 1 patient, with right coronary artery dissection.
Angioplasty with stenting failed in the patient with right coronary artery dissection. Coronary artery bypass surgery was performed in all patients. The patient with right coronary artery dissection died of sepsis on the 30th postoperative day. The other 5 patients (83.3%) are still free of symptoms, and they had negative results on stress tests at the 6- and 12-month follow-up visits after coronary artery bypass surgery.
The clinical presentation of spontaneous left main coronary artery dissection was similar to that of atherosclerotic disease. However, early diagnosis of spontaneous coronary artery dissection by means of coronary angiography is of paramount importance, because urgent coronary artery bypass grafting can be lifesaving.
Aneurysm, dissecting/diagnosis/therapy; death, sudden, cardiac/etiology; myocardial ischemia/etiology; pregnancy complications, cardiovascular; puerperal disorders; rupture, spontaneous
Myocardial infarction complicates approximately 1 in 10,000 pregnancies. Although coronary artery dissection is the leading cause of pregnancy-related myocardial infarction during the postpartum period, the pathogenesis of coronary dissection during this period remains uncertain.
Herein, we report the case of a 52-year-old black postmenopausal woman with no apparent cardiovascular risk factors who gave birth to twins after in vitro fertilization. Ten days after delivery, she presented with an acute coronary syndrome. Coronary angiography revealed dissection of all 3 coronary arteries. Despite aggressive medical management, the patient experienced recurrent myocardial ischemia. Repeat coronary angiography revealed progression of the dissection process, which required urgent coronary artery bypass surgery. The patient's postoperative course was uneventful. To our knowledge, this report is the 1st description of pregnancy-associated coronary artery dissections in a postmenopausal woman, and the 1st such event in a pregnancy that resulted from in vitro fertilization.
Chest pain/etiology; fertilization in vitro; myocardial infarction/complications; maternal age; postpartum period; pregnancy, high-risk; pregnancy complications, cardiovascular/diagnosis/etiology/radiography/therapy; postmenopause; puerperal disorders/complications/etiology/surgery; risk factors; rupture, spontaneous
Post-partum ovarian vein thrombosis is an uncommon clinical presentation. 90% of cases present as right loin and right iliac fossa pain, within 10 days of the puerperal period. Two such cases that were referred to the Imaging department as suspected appendicitis/ureteric colic are reported. The findings seen on imaging illustrate the difficulty in the clinical and radiological diagnosis of post-partum ovarian vein thrombosis and highlight the need to include it as a differential diagnosis in cases of post partum acute abdomen. Post-partum ovarian vein thrombosis can be accurately diagnosed by appropriate non-invasive investigations to enable early therapy with anti-coagulants and intravenous antibiotics which are the mainstay of treatment. Surgery can be avoided if diagnosis is made early.
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.
Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, particularly seen in women during pregnancy or in the puerperium. It has a high acute phase mortality. The etiology is uncertain. Hormonal changes during pregnancy, hemodynamic stress and changes in the autoimmune status have been considered as possible etiological factors. A timely diagnosis and institution of appropriate treatment is important for a successful outcome. There is no consensus of opinion for optimal treatment. Conservative management, coronary artery bypass graft surgery, and percutaneous coronary intervention, all have been described in the literature as possible therapeutic options. Spontaneous coronary artery dissection should be considered as a differential in any young woman presenting with chest pain associated with pregnancy. We report two cases of pregnancy-associated spontaneous coronary artery dissection, both successfully managed, along with a comprehensive review of the previously published literature.
Acute coronary syndrome; pregnancy-associated coronary artery dissection; pregnancy-related myocardial infarction; spontaneous coronary artery dissection
A 29 year old woman had a myocardial infarction three weeks post partum. Coronary angiography was performed six days later. No abnormalities were seen initially, but re-injection of the left coronary artery resulted in a dissection that extended through the anterior descending and circumflex branches and a reinfarction. This case suggests that myocardial infarctions occurring in patients with angiographically normal coronary arteries may be caused by dissections that heal by the time of catheterisation.
Five cases of spontaneous coronary artery dissection (SCAD) are reported, three in women and two in men (mean age 44 years; range 28-65), all of whom suffered a myocardial infarction. Common risk factors for coronary artery disease were present in the two men; in the female group one patient was taking an oral contraceptive, one was in the postpartum period, and the third was a smoker. Only the three women received intravenous alteplase and their ejection fraction was normal; both men had impaired left ventricular function. Two patients had SCAD of the left anterior descending coronary artery and three of the right coronary artery. Only the two men had angiographic features of coronary atherosclerotic involvement. No patients required surgical revascularisation or percutaneous transluminal coronary angioplasty. At a mean follow up of 27 months (range 6 to 40) all patients were alive and all but one were asymptomatic.
Spontaneous coronary artery dissection is a very uncommon cause of acute coronary syndrome. It occurs predominantly in young to middle-aged women during or after pregnancy. The aetiology remains uncertain. Possible factors are hormonal changes, haemodynamic stress and changes in autoimmune status. In case of single-vessel dissection and normal blood flow, conservative treatment often leads to complete angiographic resolution. This case report describes the clinical presentation, diagnosis and therapy of spontaneous coronary artery dissection in a 37-year-old woman in the postpartum period. (Neth Heart J 2008;16:412-4.)
postpartum; coronary artery; dissection
Spontaneous coronary artery dissection is a rare cause of acute myocardial ischaemia. Eight consecutive fatal cases which occurred in women aged 34-54 years (mean 43) are described. The dissection involved the left anterior descending coronary artery in four, the left main trunk in two, the right coronary artery in one, and both left anterior descending and circumflex arteries in one. The clinical presentation was sudden death in six cases, and acute myocardial infarction in two. Diagnosis was made at necropsy in every case but one, in which coronary dissection was diagnosed during life by selective coronary angiography. The only ascertained risk factor was hypertension in one patient; none of the women was in the puerperium, and Marfan syndrome was excluded in all. Histology showed a haematoma between the coronary tunica media and adventitia, that flattened and occluded the lumen; a coronary intimal tear was detected in only two cases. Unusual histological findings were cystic medial necrosis in one case, eosinophilic inflammatory infiltrates in four, and angiomatosis of the tunica adventitia in one. Patients dying of spontaneous coronary dissection are usually middle aged women, with no coronary atherosclerosis and apparently no risk factors. Spontaneous coronary artery dissection is unpredictable, and sudden death is the usual mode of clinical presentation. Prompt diagnosis and life saving treatment is far from being achieved.
Spontaneous coronary artery dissection is a rare entity being increasingly diagnosed as a cause of acute myocardial infarction, especially in cases of low cardiac risk female patients. This is one such case report of a black female patient, who suffered an acute anterior wall myocardial infarction due to an idiopathic spontaneous coronary artery dissection of the left anterior descending artery. She was treated with a thrombolytic agent in the acute phase, uneventfully. An urgent coronary angiogram demonstrated an intimal tear with a dissection of the left anterior descending artery. She survived the acute event and her subsequent hospital course was uncomplicated. Hence she was treated medically for her ischemic event and left ventricular systolic dysfunction with a favorable outcome. This case is yet another report of a survivor treated with a thrombolytic agent for the acute myocardial infarction due to spontaneous coronary artery dissection.
Spontaneous coronary artery dissection (SCAD) is a rare condition that can result in unstable angina, acute myocardial infarction, and sudden death. This condition may occur particularly in women during late pregnancy and in the postpartum period. We present the case of a 33-year-old African American woman, who had spontaneous left anterior descending coronary artery (LAD) dissection two weeks postpartum, resulting in acute ST-segment elevation myocardial infarction with severe left ventricular dysfunction. The use of the intravascular ultrasound (IVUS) in our case confirmed the diagnosis and helped with stent sizing and implantation. On subsequent follow-up, there was marked left ventricular function recovery and clinical improvement.
Ultrasonography, intreventional; Coronary vessels; Dissection; Coronary angiography; Myocardial infarction
Spontaneous internal carotid artery dissection is not an uncommon cause of ischaemic stroke in younger patients, but multiple cervical arterial dissections at presentation are uncommon. Recurrence of dissection in a previously normal artery is common. In this case report we review the history, clinical findings and management of a 42-year-old woman who presented with stroke and Horner syndrome and was found to have spontaneous bilateral internal carotid artery dissection. She was not anticoagulated due to concerns relating to the size of her infarct. She was treated with a combination of aspirin and clopidogrel. We use dual antiplatelets for the management of cervical dissections as a part of the CADISS trial. The patient made good progress with the multidisciplinary team and was discharged on day 22 with support from the community stroke team.
Treatment and prognosis of 14 patients of posterior fossa arterial dissections (AD) and dissecting aneurysms (DA) in one institution was reviewed. Internal trapping of aneurysm was performed for six patients presenting with SAH (three Vertebral, one posterior cerebral, one posterior inferior cerebellar, one anterior inferior cerebellar DA). The patency of the parent arteries was preserved in four DA patients with SAH (two Vertebral, two Basilar DA), 1 incidental vertebral DA, and one DA patient with brainstem infarction using stents and coils (four patients) or coils only (two patient). Proximal occlusion of parent artery was performed in a vertebral DA with SAH. One patient with a superior cerebellar DA presented with a midbrain infarct developed SAH with spontaneous occlusion of the aneurysm two weeks later. Of the 14 cases, ten were angiographically stable or cured during a follow up period of four to 70 months. one spontaneously resolved and two recurred. There was one death.
dissecting aneurysms, posterior fossa dissections, endovascular techniques, subarachnoid haemorrhage, infarct
Fifty percent of aortic dissections in women younger than 40 years occur in association with pregnancy. Of these, half of type B dissections occur in the postpartum period.
A 30-year-old woman was status post spontaneous vaginal delivery at 30 weeks of gestation for fetal death, complicated by an eclamptic seizure. On post-partum day 4, she suffered an acute, complicated type B aortic dissection treated with endovascular stent graft placement.
Endovascular repair may be an attractive option for the treatment of complicated type B aortic dissections in pregnancy and the peripartum period, with reduced maternal and fetal mortality. This may allow the fetus to remain in situ and avoid the risks of surgery and possible cardiopulmonary bypass, with little radiation risk to the fetus.
Primary or spontaneous coronary artery dissection (SCAD) is an unusual but increasingly recognized cause of acute myocardial ischemia and sudden cardiac death. Typically, SCAD presents in younger patients without conventional risk factors for coronary artery disease. It occurs more commonly in women than in men, and frequently during pregnancy or the postpartum period. Its pathophysiology is poorly understood, and there is considerable controversy regarding the optimal management of patients with SCAD-related myocardial ischemia. Therapeutic approaches include conservative medical therapy, coronary artery bypass graft surgery and percutaneous coronary intervention (PCI). We present four cases of SCAD to illustrate specific aspects of the presentation and management of this condition, with particular reference to the importance of intravascular ultrasound (IVUS) to aid diagnosis and guide subsequent PCI.
Coronary artery injury after blunt chest trauma is very rare, but this can result in a serious acute myocardial infarction. Coronary artery dissection is an uncommon complication of thoracic injuries. We report a case of a 17-year-old male who was presented with an anterior myocardial infarction following blunt chest trauma after a bicycle accident. His coronary angiography revealed aneurysmal dilatation with dissection of the distal left main stem coronary artery. Intravascular ultrasound showed a dissecting flap at the left main stem coronary artery. The patient was treated conservatively and discharged without serious sequelae. When symptoms and electrocardiographic findings are compatible with acute myocardial infarction, careful evaluation is important in patients with thoracic injuries for proper management. If the patient is stable, medical therapy may be appropriate. But early intervention should be considered in the presence of ongoing myocardial ischemia.