Spontaneous Healing of Spontaneous Coronary Artery Dissection: A Case Report
Author Affiliations: From the Cardiology Department, Istanbul Bilim University, Florence Nightingale Hospital, Istanbul, Turkey. The authors report no conflicts of interest regarding the content herein. Manuscript submitted January 8, 2008, provisional acceptance given March 19, 2008, and accepted March 28, 2008. Address for correspondence: Prof. Vedat Aytekin, Cardiology, Abide-i Hurriyet caddesi No:290, Istanbul Bilim University, Florence Nightingale Hospital, Istanbul, Turkey. E-mail: vaytekin@superonline.com
_______________________________________________ ABSTRACT: Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of myocardial ischemia. It is more prevalent in young women, particularly in the peripartum period. We report a case of SCAD occurring in a 40-year-old non-pregnant woman who presented with acute coronary syndrome. Coronary angiography revealed dissection in the mid and distal portions of left anterior descending artery. She was treated with medical therapy and repeat coronary angiography at 2 months showed no signs of the previous dissection.
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J INVASIVE CARDIOL 2008;20:E237–E238 Spontaneous coronary artery dissection (SCAD) is a rare condition that was first described in 1931 by Pretty.1 It occurs in relatively young people, particularly in females.2 The etiology of SCAD is unknown. It is commonly observed in three groups of patients: 1) women in the peripartum period (also includes early postpartum women); 2) patients with coronary artery disease; and 3) an idiopathic subset of patients. In 80% of the reported cases, the left anterior descending coronary artery (LAD) is involved.3 Although medical therapy and percutaneous or surgical revascularization procedures are all successful strategies, the optimal strategy is yet to be defined. We report the case of a 40-year-old non-pregnant woman with SCAD of the LAD which showed healing of the dissection with medical treatment after 2 months. Case Report. A 40-year-old non-pregnant woman with no risk factors for atherosclerosis was admitted to the hospital with the complaint of retrosternal chest pain lasting for 20 minutes. She has no history of connective tissue disorders, drug abuse or recent trauma. On admission her electrocardiogram (ECG) showed transient ST-segment elevation of 2 mm in leads V3–6. Creatine kinase (CPK) and CPK-MB were not increased, but subsequent troponin-T elevation (0.73 ng/ml) was observed 6 hours after admission. A physical examination of the patient was unremarkable. Because of the transient appearance of ST-segment elevation, primary percutaneous coronary intervention was not performed and treatment with aspirin, unfractionated heparin and a beta-blocker was started. Her symptoms were resolved with this therapy, and elective cardiac catheterization was performed on the fifth day of hospitalization. Coronary angiography revealed a long dissection starting from the mid-LAD segment and reaching the distal LAD segment (Figure 1). The other coronary arteries were normal. Left ventriculography showed mild anterolateral hypokinesia. Upon discussion with the patient about the risks and benefits of intervention, a conservative strategy was chosen. The patient was discharged from the hospital with aspirin 1 x 100 mg, clopidogrel 1 x 75 mg and atenelol 1 x 50 mg. Two months later, due to atypical chest pain, coronary angiography was repeated and showed complete resolution of the coronary dissection (Figure 2). At follow up 6 months after the event, the patient remained asymptomatic. Discussion. SCAD is a rare but well recognized cause of acute coronary syndromes. Seventy-five percent of cases occur in females with a mean age of 40 years, 33% of whom are peripartum.4 The LAD is the most common location of dissection.3 The cause of SCAD, especially idiopathic types, has still not been completely explained, but some factors such as connective tissue disorders, hypertension, smoking and strenuous physical activity have been considered as predisposing factors.5–8 Clinical presentation of SCAD varies from unstable angina, myocardial infarction and sudden death, underlining the serious nature of this entity.2 Literature from early last century is replete with postmortem diagnoses of coronary dissections, suggesting the diagnostic difficulty faced in the pre-angiographic era. Unlike dissection that can occur with percutaneous procedures, SCAD is characterized by a dissection plane involving the outer media or between the media and adventitia. The pattern and severity of clinical presentation are primarily related to the extent of dissection and its rate of development. Therapy depends on the number of vessels involved, the site of dissection and the distal coronary blood flow. Surgical revascularization is the therapy of choice when dissection involves the left main artery or several vessels.9 In the case of a well-localized symptomatic single coronary dissection, percutaneous coronary intervention with stenting is possible.10 While deploying a stent can tack down the dissection flap, it can also mobilize the intramural thrombus up or downstream, thereby extending the dissection. Deploying the stent in the false lumen can obliterate the true lumen, further complicating the situation. Using an over-the-wire ballon to inject dye distally before stent deployment, employing continuous dye infusion with an infusion catheter — ideally under intravascular ultrasound guidance — are several ways to avoid the false lumen. Medical therapy is usually considered in hemodynamically stable patients with no signs of ischemia.7,10 Spontaneous healing of the dissection has been reported in rare cases.10,11 Optimal medical therapy for SCAD has not been clearly defined. Acute coronary syndrome patients with SCAD usually receive standard medical treatment including aspirin, heparin and beta-blockers during their hospital course. However, there is little evidence on the adequate duration of antiplatelet therapy and the role of clopidogrel in the idiopathic subset of patients with SCAD. Maeder et al reported 3 cases of idiopathic SCAD that were healed with medical treatment including clopidogrel.10 Our data also provide additional evidence for the use of clopidogrel in this group of patients. In conclusion, our case report has showed that medical treatment with aspirin, clopidogrel and beta-blockers may lead to complete angiographic healing in a stable SCAD patient.
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