Coronary artery dissection

Overview

A coronary artery dissection (also known as spontaneous coronary artery dissection, or SCAD) is a rare, sometimes fatal traumatic condition, with eighty percent of cases affecting women. The condition may be related to female hormone levels, as it is often seen in post-partum women, or in women during or very near menstruation, but not always. It is not uncommon for SCAD to occur in people in good physical shape and with no known prior history of heart related illness. It is also not uncommon for SCAD to occur in people in their 20's, 30's, and 40's, as well as older.

Early studies of the disease placed mortality rates at around 70%, but more recent evidence suggests a figure of around 20%. The condition is often seen to be related to female hormone levels, as well as other pre-existing cardiovascular conditions. In addition to this, a dissection can occur iatrogenically, by the surgical inserion of a catheter into the coronary artery.

Source: Wikipedia

Symptoms

The coronary artery develops a tear, causing blood to flow between the layers which forces them apart, potentially causing a blockage of blood flow through the artery and a resulting heart attack.

Causes

There is evidence to suggest that a major cause of spontaneous coronary artery dissection (SCAD) 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 may sometimes be causes. There is also a possibility that exercise can be a trigger.

Diagnosis

SCAD's have been known to occur during exercise and at rest. SCAD's are usually diagnosed by angiogram and stenting may be necessary to re-open the artery. A dissection can also occur iatrogenically, during the surgical insertion of a catheter into the coronary artery.

Prognosis

The overall mortality in reported cases of the peripartum group is 38%. Patients with atherosclerosis as an underlying disease are thought to have a better prognosis due to collateral circulation which may develop due to chronic atherosclerosis.Also men tend to have a better chance of survival compared with women, who have an even worse prognosis when they are not in the peri- or postpartum period. In general, it can be stated that the long-term prognosis of patients with SCAD is favourable if they survive the acute phase. Although survival rates and prognosis of patients who present with SCAD vary widely in the literature, data extracted from small series and case reports show survival rates between 70 and 90%. In a review comprising 152 cases over the last 50 years, Kamineni et al. reported that 50% of patients with SCAD developed a recurrent dissection within two months. We can confirm these findings because both our patients had a recurrent dissection either in a vertebral artery or a coronary artery within one week after the first event. This suggests an enhanced susceptibility to spontaneous dissections in the acute phase. The high chance of developing a recurrent dissection is indicative for a general vessel weakness. This hypothesis is confirmed by the observation that in more than 40% of pregnant SCAD patients, dissections could be demonstrated in more than one vessel. So it seems that there is a systemic susceptibility to dissections at a certain point in life, which is marked by the initial event. Therefore we recommend monitoring patients with SCAD for at least one week in the hospital.

Source:

Maeder M, Ammann P, Angehrn W, Rickli H. Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Card 2005;101:363-69.

Kamineni R, Sadhu S, Alpert JS. Spontaneous coronary artery dissection: report of two cases and a 50-year review of the literature. Cardiol Rev 2002;10:279-84.

De Maio SJ Jr, Kinsella SH, Silverman ME. Clinical course and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989;64:471-4.

Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: two cases and review of the literature. Catheter Cardiovasc Interv 2001;52:88-94.

Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature. Eur J Cardiothorac Surg 2001 ;20:573-6.

Treatment

Treatment depends on the location and severity of the dissection. Coronary Artery Bypass Graft (CABG) surgery may be necessary in some cases. Some cases may be treated with just medication. Incidences of repeat SCADs seem to be rare, but have happened. There may be a connection between certain connective tissue disorders and SCAD. Your doctor may want to perform tests to rule that out.

Resources

Spontaneous Coronary Artery Dissection (SCAD)