Spontaneous coronary artery dissection
|Spontaneous coronary artery dissection|
|Other names||Coronary artery dissection|
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. Studies of the disease place the mortality rate at around 70%.
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
The symptoms are often very similar to those of myocardial infarction (heart attack), with the most common being persistent chest pain. Other symptoms can include rapid heartbeat, shortness of breath, sweating, extreme tiredness, nausea, and dizziness.
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. There is also a possibility that vigorous exercise can be a trigger. However, many cases have no obvious cause.
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.
A selective coronary angiogram is the most common method to diagnose the condition, although it is sometimes not recognised until after death. Intravascular ultrasound (IVUS) is also used as it is able to more easily differentiate the condition from atherosclerotic disease.
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. In severe cases, coronary artery bypass surgery is performed to redirect blood flow around the affected area. Drug-eluting stents and thrombolytic drug therapy are less invasive options for less severe cases. 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.
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. Spontaneous coronary artery dissection is the most common cause of pregnancy-associated myocardial infarction 
Spontaneous coronary artery dissection was first described in the year 1931, at postmortem examination, in a 42 year old woman.
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