a b s t r a c t

Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women in reproductive age, representing a clinical con- dition that could predispose to cardiovascular diseases. We report a case of a 34-year-old woman with PCOS, pre- senting with chest pain, onset two days before, and ST segment-elevation myocardial infarction. She was not pregnant or in a postpartum state. Subsequent cardiac angiography revealed spontaneous left anterior descend- ing coronary artery dissections, managed by conservative approach. The patient was discharged in medical ther- apy after 5 days. This is the first observation of Spontaneous coronary artery dissection occurring in a PCOS patient.

(C) 2016

Introduction

Spontaneous coronary dissection (SCAD) is a clinical condition pre- senting as an acute coronary syndrome (ACS), observed more frequent- ly in women, with an estimate incidence between 0.1 and 1% of all ACS [1]. Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women in reproductive age, representing a clinical condition that could predispose to cardiovascular disease, due to the metabolic impairment, resulting in increased Metabolic syndrome risk incidence [2]. We report a very pe- culiar clinical case, never previously described, of SCAD in a young woman with PCOS.

Case report

A 34-year-old woman with history of PCOS was referred to our in- tensive coronary unit due to ACS. She had not history of coronary artery disease, nor a personal or family history of connective tissue disorder or vasculitis. She had never been using oral contraceptives or smoking, but she was in overweight. She complained for clinical symptoms onset, in- cluding chest pain and dyspnea, started two days before.

Electrocardiogram showed normal sinus rhythm with ST segment elevation and negative T-wave in the anterior and lateral leads (Fig. 1 panel A). Cardiac enzymes were elevated (troponin I, 8300 pg/ml;

Abbreviations: SCAD, spontaneous coronary dissection; ACS, acute coronary syndrome; PCOS, polycystic ovarian syndrome; LV, left ventricular.

* Corresponding author at: Department of Advanced Medical Sciences, Federico II University, Via S. Pansini 5, 80131 Naples, Italy.

E-mail address: [email protected] (L. Spinelli).

normal range 0-16 pg/ml). Transthoracic echocardiography showed a moderate reduction of left ventricular (LV) ejection fraction (40%), with akinesia of the apex and the mid segments of the interventricular septum and the anterior wall (Fig. 2). No significant valvular regurgita- tion, as well as aortic abnormalities were observed. Selective coronary angiography demonstrated lack of coronary atherosclerotic lesions and evidence of coronary dissection on the mid segment of the left an- terior descending coronary artery, owing a reduced contrast agent flow in the distal tract of the vessel (Fig. 1 panel B, see arrow). A dual an- tiplatelet therapy (aspirin and ticagrelor) was started and patients remained asymptomatic for chest pain and dyspnea during the hospi- talization. After 5 days she was discharged in medical therapy, consisting in high dose statin, ?-blocker agents in addition to dual anti- platelet therapy. In-hospital serial echocardiography controls demon- strated no improvement of LV function parameters, rather a slight and progressive increase in both LV end-diastolic and end-systolic volumes, owing a moderate reduction of LV ejection fraction.

Discussion

The incidence of PCOS among women in reproductive age is estimat- ed between 4% and 12%. Despite its heterogeneous nature, clinical pre- sentation is characterized by hyperandrogenism and chronic anovulation [2]. Recently it has been demonstrated the key role of the insulin resistance, influencing the long-term issues of type 2 diabetes mellitus and leading to an increased risk of coronary artery disease [3]. This is the first observation of SCAD in patient with PCOS, arising the suspicion for another possible link between endocrinological disor- ders and acute coronary syndromes.

http://dx.doi.org/10.1016/j.ajem.2016.12.040

0735-6757/(C) 2016

936.e6 M. Mirra et al. / American Journal of Emergency Medicine 35 (2017) 936.e5-936.e7

Fig. 1. Panel A, Electrocardiography at admission, sinus rhythm with ST-T elevation and T-wave inversion in the anterior and lateral leads can be appreciated. Panel B, Cardiac catheterization of left coronary artery, arrows indicate the spontaneous coronary artery dissection of the mid segment of Left Descending with a reduced contrast agent flow in the distal tract of the vessel.

Fig. 2. Panels A and B show echocardiographic left ventricular assessment in four chambers view; arrows indicate akinetic segments. Panels C and D show echocardiographic left ventricular assessment in two chambers view; arrows indicate akinetic segments.

Declaration of interests”>M. Mirra et al. / American Journal of Emergency Medicine 35 (2017) 936.e5-936.e7 936.e7

SCAD is a not frequent clinical condition representing the 0.1-1% of ACS and it is prevalently diagnosed by cardiac angiography. The com- mon clinical scenario is characterized by a young female, without Cardiovascular risk factors, presenting ST- or non-ST-elevation myocar- dial infarction [1]. SCAD pathophysiology still remains unclear, but is widely accepted that an intimal tear is the first event, leading to an in- tramural bleeding with a progressive separation between true and false lumen. However, in a lesser percentage of patients disruption of vasa vasorum may cause an intramural hematoma without a distinctive intimal rupture. In both conditions myocardial ischemia results from the true lumen reduction. A large list of predisposing pathological and physiological conditions has been reported in patients with SCAD, such as connective tissue disorders, peripartum status and use of oral contraceptives [4]. Along the insulin resistance, a possible link between PCOS and vascular disease relies in increased plasminogen activator in- hibitor-1 (PAI-1) activity, influencing connective tissue remodeling [5]. In case of SCAD the choice treatment is debated, but a conservative ap- proach, with only medical treatment, is largely endorsed, whenever is possible. Medical therapy is similar to that used in patients with acute coronary syndrome due to atherosclerotic disease. Despite the choice treatment is conservative, a Prompt diagnosis is mandatory. In our clin- ical case we observed an early increase in LV volumes indicating a neg- ative remodeling with a moderate reduction of the LV ejection fraction. These findings are uncommon in SCAD patients, usually presenting a mild reduction of the LV function with a prompt recovering over time, even if not always complete. Late diagnosis might account for LV remod- eling, but the influence of the PCOS still remains uncertain.

Conclusions

In young women, presenting chest pain and dyspnea, a spontaneous coronary dissection should be always considered even if they are not

exposed to hormonal therapy or peripartum status. This clinical case suggests that mechanisms related to polycystic ovarian syndrome might predispose to spontaneous coronary artery dissection.

Learning points

• Spontaneous coronary artery dissection should be considered for all young woman presenting with abrupt onset chest pain and dyspnea.
• Polycystic ovarian syndrome might be a risk factor for spontaneous coronary artery dissection.
• Although clinical management of spontaneous coronary artery dissec- tion is conservative, early treatment is mandatory.

Declaration of interests

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the case report.

References

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