Spontaneous coronary artery dissection (SCAD): a case report (2024)

Introduction and Importance:

Keywords: acute coronary syndrome, coronary artery, spontaneous dissection

Introduction

SCAD is an etiology of acute myocardial infarction classified as a MINOCA. It occurs most often in female subjects with no or few cardiovascular risk factors, but other clinical profiles of patients may be affected1–3. By definition, SCAD does not include dissections of ruptured atherosclerotic plaques, and generally concerns smooth arteries free of atheroma. Recent studies show SCAD to be the cause of up to 1–4% of ACS2. We report the case of a 56-year-old female patient with no major cardiovascular risk factor who presented a SCAD revealed by an ACS. The patient was treated medically with favorable results. The interest of our work is to illustrate the effectiveness of medical treatment in patients with SCAD. Our study has been reported in line with the SCARE 2020 criteria3.

Case report

A 56-year-old female patient with no previous history of cardiovascular disease, with modifiable cardiovascular risk factors of android obesity, who presented 3 days before admission a constrictive, intense, prolonged, retrosternal chest pain radiating to the left shoulder. Clinical examination was normal, with blood pressure at 135/75mmHg and heart rate at 95beats/min, apyretic. The ECG revealed an ST-segment elevation with a convex appearance in the extended anterior leads associated with Q waves of necrosis (Fig. ​(Fig.1).1). The results of the transthoracic echocardiography showed akinesia of the apex and septoapical segment, hypokinesia of the basal and middle segment of the inferoseptal wall, with an ejection fraction of 59%. The biological workup showed a troponin level of more than 1000 times normal and the rest was unremarkable. The patient was admitted at the interventional catheterization room and the coronary angiography performed via the femoral artery showed a spontaneous dissection of the left descending artery coronary, with no atheromatous lesion (Fig. ​(Fig.2).2). The patient received medical treatment based on aspirin and beta-blockers with favorable evolution. She was evaluated 6 weeks later with favorable results (Fig. ​(Fig.33).

Discussion

SCAD is defined as an epicardial coronary artery dissection that is not associated with atherosclerosis or trauma and not iatrogenic. Recent studies suggest SCAD to be a cause of up to 1–4% of ACS2,3. The demographic characteristics of the classic patient are young women of 41–52 years of age with no typical atherosclerotic risk factors4 The development of SCAD can be explained by two interrelated mechanisms5,6: Inside-out” phenomenon: blood extravasation from the intima to the media following a rupture of the intima (creating an intimal flap) accessible to an angiographic diagnosis. The ‘outside-in’ phenomenon: The vasa vasorum located at the level of the media ruptures, resulting in the occurrence of an isolated intramural hematoma without access to the arterial lumen (Fig. ​(Fig.4).4). In both situations, the false channel, usually in the outer one third of the media, tends to extend and compress the true channel, leading to myocardial ischemia.

Meta-analyses of case series including atherosclerotic and nonatherosclerotic SCAD suggest that it presents as ST-elevation myocardial infarction in 48%, as non–ST-elevation myocardial infarction in 36%, and as unstable angina in 6.5%. Stable angina, congestive heart failure, and ventricular arrhythmia account for the remainder of presentations; 8–14% of cases present as life-threatening arrhythmia7,8 Coronary angiography remains the ‘first-line’ examination in case of suspected ACS and is the gold standard for the diagnosis of SCAD. The classification of Saw et al.6,9,10 describes angiographic signs which are widely adopted (Fig. ​(Fig.5).5). In the Saw angiographic SCAD classification6,9,10, type 1 refers to the classic appearance of multiple radiolucent lumens or arterial wall contrast staining. Type 2 refers to the presence of diffuse stenosis that can be of varying severity and length (usually more than 20mm). Type 3 is focal or tubular stenosis, usually less than 20mm in length that mimics atherosclerosis. Type 4 is described as a distal occlusion of the artery.

The use of endocoronary imaging such as optical coherence tomography and intravascular ultrasound is necessary in case of diagnostic doubt (especially in SCAD type 2 and 3)11.

According to available data, with the exception of very high-risk profile patients, a conservative approach should be the preferred strategy for SCAD management. It is recommended to associate aspirin with beta-blockers12. The time course of healing remains uncertain, but it is frequently observed by 1 month2,13.

SCAD management has been codified in the 2020 recommendations of the European Society of Cardiology of the European Society of Cardiology (Fig. ​(Fig.66).

Conclusion

Spontaneous coronary dissection, a particular form of ACS, is classified as MINOCA according to the latest recommendations and remains a challenge in terms of diagnosis and management. Its predominance is female, occurring classically in young women with little or no cardiovascular disease. It should therefore be considered in any young woman presenting with suspicious chest pain with positive troponin. The diagnosis is initially angiographic and may require endocoronary imaging for greater accuracy. Conservative treatment (i.e. medical) remains the best option since in the majority of cases the evolution is favorable.

Provenance and peer review

Not commissioned, externally peer reviewed.

Ethical approval

Not applicable.

Consent

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 on request.

Sources of funding

None.

Authors’ contribution

All authors have contributed to this case report.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Driss Britel.

Footnotes

References