Spontaneous coronary artery dissection in 72-yrs-old male presenting with ACS: A case report of IVUS-guided PCI

Tóm tắt

Background

Spontaneous coronary artery dissection (SCAD) is a rare non atherosclerotic cause of acute coronary syndrome (ACS). Literature highlights its low incidence and it is estimated to only comprise 0.07-0.2% of angiograms for ACS. Approximately 90% of SCAD patients are women, and factors such as the hormonal changes of the menstrual cycle are thought to be relevant. It is therefore interesting to consider why patients without such hormonal exposure may be affected. SCAD in men remains poorly understood.

Methods

We present a case of a 72 year old male  who presented with chest pain, palpitations and exertional dyspnea. He is a known hypertensive with dyslipidemia. He had prior history of acute coronary syndrome with mild coronary artery disease on angiogram. He was apparently asymptomatic interim. 1 week prior to admission, patient had sudden onset chest pain with ECG showing ischemic changes and 2D echocardiography with Doppler revealing reduced ejection fraction and wall motion abnormality. Coronary angiography was subsequently done with findings of  spontaneous coronary artery left circumflex artery dissection (LCX) dissection with severe coronary artery disease of the left anterior descending artery (LAD) and documented via intravascular ultrasound (IVUS) and eventually underwent percutaneous coronary intervention and was discharged improved.

Results

Spontaneous coronary artery dissection (SCAD) is defined as an epicardial coronary artery dissection that is not associated with atherosclerosis or trauma. The predominant mechanism of myocardial injury occurring as a result of SCAD is coronary artery obstruction caused by formation of an intramural hematoma (IMH) or intimal disruption rather than atherosclerotic plaque rupture or intraluminal thrombus.^[2] In addition, SCAD has unique risk factors and associated conditions and different diagnostic, therapeutic, and prognostic implications compared with atherosclerotic coronary disease.

The characteristics of men with SCAD are less well described. A Canadian SCAD study by McAlister documented that out of 1,173 patients with SCAD, 123 (10.5%) were men. Men with SCAD were younger than women (mean age 49.4 ± 9.6 years vs 52.0 ± 10.6 years; P = 0.01). Men had lower rate of prior myocardial infarction than women (0.8% vs 7.0%; P = 0.005). There was no difference in angiographic types of SCAD, but men had more circumflex artery (44.4% vs 30.9%; P = 0.001) and fewer right coronary artery (11.8% vs 21.7%; P = 0.0054) dissections. At median follow-up of 3 years, men had fewer hospital presentations with chest pain (10.6% vs 24.8%; P < 0.001). There were no differences in in-hospital events or follow-up major adverse cardiovascular events (MACE) (7.3% vs 12.7%; P = 0.106).^[3] This was coinciding with the profile of our patient with circumflex artery involvement and presenting with chest pain although older in age.

Conclusion

Spontaneous coronary artery dissection (SCAD) is an important cause of ACS in otherwise healthy young and middle-aged individuals and men represent an important minority (∼10%) of SCAD patients. It is frequently underdiagnosed or misdiagnosed and can potentially result in substantial morbidity and mortality; a heightened suspicion for SCAD is required for accurate diagnosis and treatment.