American Journal of Emergency Medicine 31 (2013) 1156.e1-1156.e3

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American Journal of Emergency Medicine

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Case Report

A successful emergency management of Spontaneous coronary artery dissection and review of the literature

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare and lethal myocardial ischemic event, which usually causes acute coronary syndrome and sudden death. Emergency management of SCAD includes medical treatment, percutaneous coronary interventions, and Coronary artery bypass grafting. Here, we report 1 case of 37- year-old young woman who was found to have a mid-distal SCAD of the left anterior descending artery, taking conservative management decision. In another case of a 50-year-old woman who was found to have a proximal-middle spiral SCAD of the right coronary artery, she underwent coronary angioplasty. After 6 months later at follow-up, 2 patients remained stable without symptom and in recovery of the left ventricular function; angiogram showed the SCAD healed.

Spontaneous coronary artery dissection (SCAD) is a rare clinical event occurring more commonly in woman. The first reported autopsy of a 42-year-old woman with SCAD was in 1931 [1]. From 1931 to 2012, more than 490 cases of SCAD are reported [2]. Spontaneous coronary artery dissection usually causes acute coronary syndrome and sudden death [3]. Two-third of these occurred in pregnancy or postpartum period [4,5]. Currently, the clinical recognition of SCAD has increased as coronary angiography is used frequently in the clinical evaluation of patients with acute coronary syndromes. Furthermore, intravascular ultrasound (IVUS) tomography have been enabled to provide a more detailed lumenal information to SCAD [6,7]. At present, literature showed that SCAD might concomitant fibromuscular dysplasia (FMD), whether fibromuscular dysplasia predisposed to SCAD, without proof from histology or intracoronary imaging of the affected coronary arteries [8,9].

As a result of SCAD, clinical presentation includes unstable angina, acute myocardial infarction, and ventricular arrhythmias to sudden cardiac death. Most of patients die suddenly or within a few hours of symptom onset, survivors of patients receive proper diagnosis, and treatment usually has good prognosis [3]. Here, we report 2 patients who were admitted in the emergency department (ED) and provided for successful emergency management. One is a 37-year-old woman, in consideration of the stable hemodynamics and the middle-distal left anterior descending artery (LAD) dissection; we chose a conservative strategy. Another is a 50-year-old woman in consider- ation of the diffused and complexed proximal RCA and was deployed with stent successfully. Two different management options in patients and follow-up are discussed.

A 37-year-old woman, without a history of cardiovascular disease and no coronary risk factor, was urgently admitted to our hospital with

rest crushing chest pain, which had started 2 day before. Initial electrocardiogram (ECG) demonstrated minimal anterior ST-segment elevation in lead V₂ through V₄. T-wave inversion in leads V₃ to V₅ and chest x-ray showed mild bilateral prominence of interstitial markings with slight enlargement of the cardiac silhouette. Initial laboratory tests were significant for elevated levels of troponin I at 8.7 ng/mL, creatine kinase at 697 U/L, and creatine kinase-MB at 48.1 ng/mL. A bedside echocardiogram revealed akinesis of interventricular septum and apex as well as ejection fraction of 46%. The patient was immediately taken to the catheterization laboratory; subsequent coronary angiogram revealed Spontaneous dissection of the middle LAD extending into LAD distally (Fig. 1A). There was an 80% stenosis of the true lumen of the middle segment of the LAD caused by external compression by the hematoma in the false lumen. The distal LAD has a TIMI3 flow. The left circumflex artery (LCX) and the right coronary artery are normal. At the same time, the patient was taken to the IVUS examination; IVUS also enables assessment of the length and morphology of the intramural dissection and the detection of an intimal tear if present , corresponding IVUS showing LAD cross-section hematoma (in the false lumen) (Fig. 1B). Because the dissection originated from the middle LAD and extended to the distal LAD as well, the dissection length is longer. In view of the angiogram finding, the extent of the dissection reaching the very distal LAD limited revascularization options to either coronary angioplasty or bypass surgery. Conservative management decision was taken. Aspirin, clopidogrel, statin, and angiotensin- converting enzyme inhibitors have been used. One week later, the patient symptom was stable, and she was discharged home; 6 months later at follow-up she was better with no symptom and cardiac events. Angiogram showing the LAD dissection has been healed (Fig. 1C).

A 50-year-old woman was presented in the ED of our hospital

because of chest pain for 2 hours, while she was doing farm work in the morning. Initial ECG showed ST-segment elevations(1-3 mm) in the inferior leads (I, II, aVF) and ST-segment depressions in high lateral leads (V₄, V₅, V₆). A chest radiograph was normal. While in the ED, the patient blood pressure was 100/60 mm Hg; the pulse, 60 to 70 beats per minute; the respiratory rate, normal; and the oxygen saturation, 95% to100%, while she was breathing oxygen (2 L by nasal cannula). emergency coronary angiography revealed a normal left main coronary artery, mild atherosclerosis in the LAD, normal in the LCX, and a long spiral dissection in the proximal-middle RCA, since there was TIMI2 to 3 flow and the dissection multiple true-false lumen from proximal RCA spiral teared to the middle; the true lumen was obscure and unclear (Fig. 2A). After finished angiography, because the dissection of RCA might induce severe myocardial ischemia or sudden death, but the patient refused further bypass angioplasty revascular- ization, so coronary angioplasty with stenting was recommended. We

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Fig. 1. A, Angiogram showing coronary artery dissection in the mid to distal LAD (arrow). B, The IVUS showed false lumen and intramural hematoma(white arrow). *F, false lumen. C, Angiogram showing LAD dissection healed.

prepared to perform coronary angioplasty in patient; the guide wire, however, was permitted to cross the lesion (true lumen), which was passed very difficult. Finally, undergoing double wire skill crossed the lesion, a balloon repeat dilated, and a stent was deployed successfully, angiographic results were very excellent (Fig. 2B-D). The patient was discharged on aspirin, clopidogrel, and statin, and she remained asymptomatic after 6 months of follow-up.

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome and sudden death [10]. More than 70% of SCAD cases are women. The pathogenesis of SCAD is unknown and probably multifactorial [8]. Peripartum state, connective tissue disease, immune system alterations, cocaine-abused association with coronary artery spasm, and oral contraceptive drugs are

known to be involved in SCAD. Spontaneous coronary artery dissection is defined as a separation of the coronary arterial wall by hemorrhage, with or without an associated intimal tear [9-11]; an intimal tear is only seldom observed, blood or clot accumulation results in a false lumen, expansion of false lumen extends to distal propagation of the dissection and to compression of the real lumen, and the ratio of real/ false lumen, to some extent, correlates with myocardial ischemia. The LAD is the most frequently involved vessel in autopsy, and in angiographic series, the LAD accounts, on average, for 60% of the cases, LCX or RCA seldom occurred, and sometimes, multivessel dissections occurred as well [12,13].

In women younger than 50 years, the prevalence of SCAD increased up to 8.7% and reached 10.8% in the case of ST-elevation

Fig. 2. A, Angiogram showing coronary artery dissection in the mid to distal LAD showing coronary artery spiral dissection in the proximal to distal RCA (white arrow). B to D, One week later, the patient dissection of the RCA was dilated with a balloon and was deployed with a stent and with excellent angiographic results.

Y. Xin-He et al. / American Journal of Emergency Medicine 31 (2013) 1156.e1–1156.e3 1156.e3

myocardial infarction [12]. If a young woman’s chief complaint chest pain with ST-segment elevation or ST-segment depression in ECG and without any risk factors, the clinician should have a high grade of suspicion for SCAD, and emergency angiography should be consid- ered. The literature reports that dissection of the LAD is the most common location in women, whereas RCA dissection is most common in men. Its pathogenesis of SCAD is unknown and not clearly. In our 2 patients without any other risk factors, the diagnosis of patient with SCAD depends on the clinical presentation, the cardiac biomarkers information, and dissection extensive in angiogram.

Management of SCAD has not been well defined; revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting) or with medical therapy depends on angiographic finding and extensive dissection. Most patients with SCAD are usually symptomatic, and they present with chest pain, unstable hemody- namic, and even sudden death. Stable patients with mild or local vessel dissection, the real lumen over 2.5 mm, the distal coronary artery perfusion is TIMI 3 flow, without progression or Hemodynamic compromise, and without left main coronary artery involvement, otherwise, large area of myocardium in jeopardy, could be treated medically. Many of those that heal spontaneously were reported; medical management of SCAD is similar to the treatment of acute coronary syndromes [12]. It includes antithrombotic (low-molecular- weight heparin, aspirin, clopidogrel), anti-ischemic, and anti-spasm therapy (?-blockers and nitrates). If the use of multiple and potent antithrombotic therapy in SCAD is careful and cautious, on one hand, it will help decrease thrombus formation in the false lumen, allowing for more normal blood flow through the true lumen; on the other hand, it may increase bleeding in the false lumen causing an expansion of the intramural hematoma, resulting in a decreasED flow through the true lumen.

If a pronounced dissection persists in a major vessel (left main

artery, multiple vessel, or complex vessel) or in SCAD causing marked epicardial coronary flow impairment and/or ongoing ischemia, coronary artery bypass grafting should be considered to be the best choice to restore myocardial perfusion. intra-aortic balloon pump may help to maintain hemodynamic condition. Left ventricular assist device can also be used as a bridge to recovery or to Heart transplantation. If SCAD only in single vessel, angiographic assess- ment of dissection location and the extent and degree of flow compromise, PCI is considered to be the best choice as well. Percutaneous coronary intervention with stenting can restore flow in the true lumen, relieving ischemia, and seal the dissection, preventing further expansion. Technical difficulties during PCI include advancing the guide wire in the true lumen rather than in the false lumen and avoiding distal propagation of the intramural hematoma and dissection during stent delivery. Sometimes, the operator should be careful and patient, and the special skills (double wires or microcatheter) should be used; all the procedures depend on patient security and successful.

In our first case, in consideration of the stable hemodynamics and of the absence of high-risk features, IVUS examination was performed,

which showed false and true intramural starting from the middle of LAD to its distal, with mild true lumen compromise, and the presence of nonobstructive atheroma. Hence, we chose a conservative strategy. The patient was discharged on medical treatment with double antiplatelets and statin therapy, and after 6 months later at follow-up, no symptom and cardiac events reoccurred; the LAD dissection healed with angiogram. On the other hand, in our second patient, the dissection was diffused and spiral teared to the proximal of the RCA and thus underwent PCI that was deployed with stent successfully. Both patients remained stable with no cardiac events in 6-month follow-up.

Ye Xin-He MD Yang Cheng-Jian MD

Jin Yan MD Xu Xin MD

Cao Jia-Ning MD Yang Zhen-Jie MD Dong Feng MD

Department of Cardiology, Affiliated Wuxi No. 2 Hospital Nanjing Medical University, Wuxi, Jiangsu 214002, China E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.03.019

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