Spontaneous coronary artery dissection

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Spontaneous coronary artery dissection
Other namesCoronary artery dissection
SpecialtyCardiology Edit this on Wikidata

A spontaneous coronary artery dissection is a rare, sometimes fatal traumatic condition, with eighty percent of cases affecting women. One of the coronary arteries develops a tear, causing blood to flow between the layers which forces them apart.[1] Studies of the disease place the mortality rate at around 70%.[2][3]

Spontaneous coronary artery dissection is a primary cause of myocardial infarction in young, fit, healthy women (and some men) with no obvious risk factors. These can often occur during late pregnancy, postpartum and peri-menopausal periods.

Signs and symptoms[edit]

The symptoms are often very similar to those of myocardial infarction (heart attack), with the most common being persistent chest pain.[4] Other symptoms can include rapid heartbeat, shortness of breath, sweating, extreme tiredness, nausea, and dizziness.[5]

Causes[edit]

There is evidence to suggest that a major cause of spontaneous coronary artery dissection is related to female hormone levels, as most cases appear to arise in pre-menopausal women, although there is evidence that the condition can have various triggers. Other underlying conditions such as hypertension, recent delivery of a baby, fibromuscular dysplasia and connective-tissue disorders (e.g., Marfan syndrome and Ehlers-Danlos syndrome) may occasionally result in spontaneous coronary artery dissection.[6] There is also a possibility that vigorous exercise can be a trigger. However, many cases have no obvious cause.[7][8]

Pathophysiology[edit]

Coronary artery dissection results from a tear in the inner layer of the artery, the tunica intima. This allows blood to penetrate and cause an intramural hematoma in the central layer, the tunica media, and a restriction in the size of the lumen, resulting in reduced blood flow which in turn causes myocardial infarction and can later cause sudden cardiac death.[9][10][11]

Diagnosis[edit]

A selective coronary angiogram is the most common method to diagnose the condition, although it is sometimes not recognised until after death.[12][13] Intravascular ultrasound (IVUS) is also used as it is able to more easily differentiate the condition from atherosclerotic disease.[14]

Treatment[edit]

Treatment is varied depending upon the nature of the case. In asymptomatic and hemodynamically stable patients it may be appropriate to maintain a conservative strategy, especially if coronarography demonstrates adequate coronary flow: in this situation spontaneous healing is usually the most probable evolution.[15] In severe cases, coronary artery bypass surgery is performed to redirect blood flow around the affected area.[16][17] Drug-eluting stents and thrombolytic drug therapy are less invasive options for less severe cases.[14] However PCI for spontaneous coronary artery dissection is associated with high rates of technical failure, so in many case a strategy of conservative management may be preferable.

According to some sources, while heart attack patients may require a procedure, those with spontaneous coronary artery dissection may benefit from a more conservative therapy that focuses on controlling blood pressure, such as beta blockers.[18]

Prognosis[edit]

The condition is often fatal and is mostly recognized at postmortem examination in young victims of sudden death.[19][20]

Epidemiology[edit]

The prevalence of spontaneous coronary dissection varies from about 1% to 4% of all coronarography. About eighty percent of cases are in women, with an average age of around 40.[21][22][23][24] Spontaneous coronary artery dissection is the most common cause of pregnancy-associated myocardial infarction [25]

History[edit]

Spontaneous coronary artery dissection was first described in the year 1931, at postmortem examination, in a 42 year old woman.[26]

See also[edit]

References[edit]

  1. ^ Slight R, Behranwala AA, Nzewi O, Sivaprakasam R, Brackenbury E, Mankad P (2003). "Spontaneous coronary artery dissection: a report of two cases occurring during menstruation". New Zealand Medical Journal. Archived from the original on 2010-04-09.
  2. ^ DeMaio SJ, Kinsella SH, Silverman ME (September 1989). "Clinical course and long-term prognosis of spontaneous coronary artery dissection". The American Journal of Cardiology. 64 (8): 471–4. doi:10.1016/0002-9149(89)90423-2. PMID 2773790.
  3. ^ Khan NU, Miller MJ, Babb JD, Ahmed S, Saha PK, Shammas RL, Macdonald RG, Movahed A (2006). "Spontaneous coronary artery dissection". Acute Cardiac Care. 8 (3): 162–71. doi:10.1080/17482940600789190. PMID 17012132.
  4. ^ "Spontaneous Coronary Artery Dissection Postpartum"
  5. ^ "Symptoms and causes - Mayo Clinic". www.mayoclinic.org. Retrieved 2018-11-07.
  6. ^ Dhawan R, Singh G, Fesniak H. (2002) "Spontaneous coronary artery dissection: the clinical spectrum". Angiology
  7. ^ Mark V. Sherrid; Jennifer Mieres; Allen Mogtader; Naresh Menezes; Gregory Steinberg (1995) "Onset During Exercise of Spontaneous Coronary Artery Dissection and Sudden Death. Occurrence in a Trained Athlete: Case Report and Review of Prior Cases" Chest
  8. ^ {http://www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/basics/risk-factors/con-20037794}
  9. ^ Virmani R, Forman MB, Rabinowitz M, McAllister HA (1984) "Coronary artery dissections" Cardiol Clinics
  10. ^ Kamineni R, Sadhu A, Alpert JS. (2002) "Spontaneous coronary artery dissection: Report of two cases and 50-year review of the literature" Cardiol Rev
  11. ^ Kamran M, Guptan A, Bogal M (October 2008). "Spontaneous coronary artery dissection: case series and review". The Journal of Invasive Cardiology. 20 (10): 553–9. PMID 18830003.
  12. ^ C. Basso, G. L. Morgagni, G. Thiene (1996) "Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death" BMJ
  13. ^ Desseigne P, Tabib A, Loire R (July 1992). "[An unusual cause of sudden death: spontaneous dissection of coronary arteries. Apropos of 2 cases]". Archives des Maladies du Coeur et des Vaisseaux. 85 (7): 1031–3. PMID 1449336.
  14. ^ a b Intravascular Ultrasound Imaging in the Diagnosis and Treatment: The Future: IVUS-Guided DES Implantation?
  15. ^ Alfonso F, Paulo M, Lennie V, Dutary J, Bernardo E, Jiménez-Quevedo P, Gonzalo N, Escaned J, Bañuelos C, Pérez-Vizcayno MJ, Hernández R, Macaya C (October 2012). "Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy". JACC. Cardiovascular Interventions. 5 (10): 1062–70. doi:10.1016/j.jcin.2012.06.014. PMID 23078737.
  16. ^ MedHelp:Coronary artery dissection treatment
  17. ^ Tweet MS, Eleid MF, Best PJ, Lennon RJ, Lerman A, Rihal CS, Holmes DR, Hayes SN, Gulati R (December 2014). "Spontaneous coronary artery dissection: revascularization versus conservative therapy". Circulation: Cardiovascular Interventions. 7 (6): 777–86. doi:10.1161/CIRCINTERVENTIONS.114.001659. PMID 25406203.
  18. ^ "Coronary Artery Dissection: Not Just a Heart Attack". www.heart.org. Retrieved 2018-11-07.
  19. ^ Le MQ, Ling FS (August 2007). "Spontaneous dissection of the left main coronary artery treated with percutaneous coronary stenting". The Journal of Invasive Cardiology. 19 (8): E218–21. PMID 17712209.
  20. ^ Auer J, Punzengruber C, Berent R, Weber T, Lamm G, Hartl P, Eber B (July 2004). "Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound". Heart. 90 (7): e39. doi:10.1136/hrt.2004.035659. PMC 1768303. PMID 15201265.
  21. ^ Hayes, S (2013), New Insights into This Not-So-Rare Condition
  22. ^ Vanzetto G, Berger-Coz E, Barone-Rochette G, Chavanon O, Bouvaist H, Hacini R, Blin D, Machecourt J (February 2009). "Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients". European Journal of Cardio-Thoracic Surgery. 35 (2): 250–4. doi:10.1016/j.ejcts.2008.10.023. PMID 19046896.
  23. ^ Yip A, Saw J (February 2015). "Spontaneous coronary artery dissection-A review". Cardiovascular Diagnosis and Therapy. 5 (1): 37–48. doi:10.3978/j.issn.2223-3652.2015.01.08. PMC 4329168. PMID 25774346.
  24. ^ Fontanelli A, Olivari Z, La Vecchia L, Basso C, Pagliani L, Marzocchi A, Zonzin P, Vassanelli C, Di Pede F (January 2009). "Spontaneous dissections of coronary arteries and acute coronary syndromes: rationale and design of the DISCOVERY, a multicenter prospective registry with a case-control group". Journal of Cardiovascular Medicine. 10 (1): 94–9. doi:10.2459/JCM.0b013e32830f45c7. PMID 19708230.
  25. ^ Hayes SN, Kim ES, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ (May 2018). "Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association". Circulation. 137 (19): e523–e557. doi:10.1161/CIR.0000000000000564. PMC 5957087. PMID 29472380.
  26. ^ Pretty HC (18 April 1931). "Dissecting aneurysm of coronary artery in a woman aged 42". British Medical Journal. 1 (3667): 667. doi:10.1136/bmj.1.3667.667.

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