Spontaneous coronary artery dissection in a young man - Case report

Spontaneous coronary artery dissection (SCAD) is a rare and uncommon case of sudden cardiac death and acute coronary syndrome [1]. As several diseases and conditions have been associated with SCAD it therefore probably constitutes a heterogeneous entity. Risk factors for SCAD comprise pregnancy, Ehlers-Danlos disease, Marfan's Syndrome, intensive exercise, or cocaine abuse [1–4]. The clinical presentation of SCAD depends on the extent and the flow limiting severity of the coronary artery dissection, and ranges from asymptomatic to unstable angina, acute myocardial infarction, ventricular arrhythmias to sudden cardiac death. Coronary angiography is frequently used in the evaluation of patients with acute coronary syndromes. Thus, most cases with SCAD are detected by angiography. Moreover, intracoronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), which provide detailed morphological information on coronary lesions and on the location of dissection planes between the different layers of the arterial wall, have enabled a more detailed clinical assessment of SCAD. Furthermore, non-invasive coronary angiography by multidetector computed tomography (MDCT) has been used for longitudinal follow-up evaluation of patients with SCAD. There is no consensus about the way of treatment including medical therapy, interventional treatment with PCI or surgery. We present a case of SCAD complicated by the occurrence of a left ventricular thrombus in a 31 years old man admitted with an acute coronary syndrome.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome first described in 1931 [5]. The ratio female to men is 2:1 and the dissection is more frequently diagnosed in the left coronary artery [6]. Coronary artery dissection is characterized by a separation of the layers of the artery wall. This results in a false lumen or an intramural haematoma in the area of the media [2]. Coronary angiography is the primary tool for diagnosis of SCAD. Intracoronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), which provide detailed morphological information on coronary lesions and on the location of dissection planes between the different layers of the arterial wall, have enabled a more detailed clinical assessment of SCAD [2]. Furthermore, non-invasive coronary angiography by multidetector computed tomography (MDCT) has been used for longitudinal follow-up evaluation of patients with SCAD. We did not utilize IVUS in the patient presented in this report because angiographic assessment revealed high diagnostic accuracy. We did not expect further information from additional imaging that might have changed clinical decision making. SCAD occurs during pregnancy in 26,1% of the cases. In this patient population, SCAD was diagnosed most frequently during the postpartum period [7, 8]. SCAD may be associated with Marfan's Syndrome, Ehlers-Danlos Disease, intensive exercise and cocaine abuse, female hormonal treatments as oral contraceptives, although in some cases no predictor could be identified [1–4]. A hereditary factor has been discussed previously [9]. There are no randomized trials on treatment of coronary artery dissection. The literature consists of case reports and case series. Different strategies of treatment have been discussed in the last years. Conservative management of patients with SCAD is a possible treatment strategy in stabile patients [10]. Antiplatelet therapy can be used because of the flow limitations caused by platelet thrombi [1]. GP IIb/IIIa inhibitors have been successfully used in patients with SCAD [2, 11]. We did not use a GP IIb/IIIa inhibitor in the present patient because of clinical success with dual antiplatelet therapy and heparin and risk-benefit calculation with respect to the recent stoke. However, utilization of a GP IIb/IIIa inhibitor would have been our bail-out-strategy. Koller et al. reported a spontaneous healing of the lesion of a postpartum SCAD with the treatment including prednisone and cyclophosphamide combined with the conventional therapy [12]. Stent implantation can be performed in limited disease after identification of the true and false lumen [13]. Fibrinolysis is not recommended due to the increase of the bleeding risk [1]. In the case of multivessel dissection, coronary artery bypass graft (CABG) may be a reasonable choice [14]. In conclusion spontaneous coronary artery dissection is an uncommon disease, more frequently seen in women without cardiac risk factors [1]. The postpartum period, cocaine, intensive exercise and diseases like Ehlers-Danlos are risk factors for SCAD [1–4]. The management strategy has to be based on clinical presentation, additional findings and morphological details during invasive assessment in a case by case fashion.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.