Multivessel spontaneous coronary artery dissection in a patient after mild COVID-19: A case report

Spontaneous coronary artery dissection: review, case report and analysis of COVID-19-related cases

Spontaneous coronary artery dissection (SCAD) accounts for 1-4% of all acute coronary syndromes (ACS). Since the first description in 1931, our understanding of the disease has evolved; however, its pathophysiology and management are still a matter of debate. SCAD typically occurs in a middle-aged woman with no or few traditional cardiovascular risk factors. Two hypotheses have been proposed to explain the pathophysiology depending on the primary event: an intimal tear in the "inside-out" hypothesis and a spontaneous hemorrhage from the vasa vasorum in the "outside-in" hypothesis. Etiology appears to be multifactorial: different predisposing and precipitating factors have been identified. Coronary angiography is the gold standard for the diagnosis of SCAD. Current recommendations on the treatment of SCAD patients are based on expert opinions: a conservative strategy is preferred in hemodynamically stable SCAD patients, while urgent revascularization should be considered in hemodynamically unstable patients. Eleven cases of SCAD in COVID-19 patients have already been described: although the exact pathophysiological mechanism remains unclear, COVID-19-related SCAD is considered a combination of significant systemic inflammatory response and localized vascular inflammation. We present a literature review of SCAD, and we report an unpublished case of SCAD in a COVID-19 patient.

Spontaneous coronary artery dissection in patients with prior psychophysical stress: a systematic review of case reports and case series

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome, particularly in younger women. Due to limited information about SCAD, case reports and case series can provide valuable insights into its features and management. This study aimed to comprehensively evaluate the features of SCAD patients who experienced psychophysical stress before the SCAD event.

METHODS

We conducted an electronic search of PubMed, Scopus, and Web of Science from inception until January 7, 2023. We included case reports or series that described patients with SCAD who had experienced psychophysical stress before SCAD. Patients with pregnancy-associated SCAD were excluded from our analysis.

RESULTS

In total, we included 93 case reports or series describing 105 patients with SCAD. The average patient age was 44.29 ± 13.05 years and a total of 44 (41.9%) of patients were male. Among the included SCAD patients the most prevalent comorbidities were fibromuscular dysplasia (FMD) and hypertension with the prevalence of 36.4 and 21.9%, respectively. Preceding physical stress was more frequently reported in men than in women; 38 out of 44 (86.4%) men reported physical stress, while 36 out of 61 (59.1%) females reported physical stress (p value = 0.009). On the other hand, the opposite was true for emotional stress (men: 6 (13.6%)), women: 29 (47.6%), p value < 0.001). Coronary angiography was the main diagnostic tool. The most frequently involved artery was the left anterior descending (LAD) (62.9%). In our study, recurrence of SCAD due to either the progression of a previous lesion or new SCAD in another coronary location occurred more frequently in those treated conservatively, however the observed difference was not statistically significant (p value = 0.138).

CONCLUSION

While physical stress seems to precede SCAD in most cases, emotional stress is implicated in females more than males.

Spontaneous Coronary Artery Dissection as a Cause of Acute Myocardial Infarction in COVID-19 Patients: A Case Report and Review of the Literature

Patients with COVID-19 often experience significant cardiovascular complications, including heart failure, myocarditis, and acute coronary syndrome. We present the case of a male patient with severe COVID-19 pneumonia, complicated with inferior ST-segment elevation myocardial infarction (STEMI), which was attributed to spontaneous coronary artery dissection (SCAD). We also make a review of the literature on case reports of patients with COVID-19 and acute myocardial infarction due to SCAD. Through these clinical cases, a potential correlation between SCAD and COVID-19 infection is implied. Endothelial dysfunction, thrombotic complications, and disturbance of the vascular tone are established COVID-19 sequelae, triggered either by direct viral injury or mediated by the cytokines' storm. These abnormalities in the coronary vasculature and the vasa vasorum could result in SCAD. Moreover, disturbances of the vascular tone can cause coronary vasospasm, a reported precipitant of SCAD. Thus, SCAD should be considered in COVID-19 patients with acute coronary syndrome (ACS), and in the case of STEMI, an early angiographic evaluation, if feasible, should be performed rather than thrombolysis to avoid potential adverse events of the latter in the setting of SCAD.

Acute Cardiovascular Complications of COVID-19: A Systematic Review

Since the pandemic in 2019, coronavirus 2019 (COVID-19) has continued to be linked with a variety of organ systems and complications. While it is generally considered a respiratory disease, its link with the heart is widely discussed in the literature. This article focuses on the acute cardiovascular complications of COVID-19 and the possible predictors of these complications. Our study included 97 articles (58 case reports, eight case series, 23 retrospective cohort studies, five prospective cohort studies, and three cross-sectional studies). Several mechanisms have been proposed to explain COVID-19-induced cardiovascular complications, with cytokine-induced inflammation and direct cardiac damage noted as the significant focus. Patients with underlying cardiovascular complications such as hypertension and diabetes were noted to be at increased risk of acute cardiovascular complications, as well as an increased risk of severe disease and death. Also, acute myocardial infarction and arrhythmias were two of the most common acute cardiovascular complications noted in our review. Other acute cardiovascular complications are myocarditis, takotsubo syndrome, acute thromboembolic events, and pericardial complications. This article provides an updated review of acute cardiovascular complications of COVID-19, its pathogenesis, and risk stratification and emphasizes the need for high suspicion in patients with underlying cardiovascular risk factors.

Spontaneous dissection of the superior mesenteric artery related to COVID-19

Background: Spontaneous peripheral dissections are rare, and in a substantial number of cases, the underlying aetiology remains unclear. Patients and methods: We report the case of a 63-year-old male patient with a recent asymptomatic SARS-CoV-2 infection who presented with sudden-onset intermittent abdominal pain. Imaging studies revealed a dissection of the superior mesenteric artery (SMA) and large-vessel vasculitis involving the SMA as well as the carotid, subclavian, axillary and femoropopliteal arteries. In the absence of other predisposing factors, we supposed an association with prior COVID-19 and performed a systematic review of the literature to search for similar cases with arterial dissection related to acute or recent SARS-CoV-2 infection. Results: We identified 25 cases, including ours: 13 males and 12 females, with a median age of 48 years. In 22/25 patients, arterial dissection occurred within 4 weeks after the diagnosis of COVID-19 and involved the cerebral (11/25; 44%), coronary (10/25; 40%), splanchnic (3/25; 12%) and renal (2/25; 8%) arteries. Conclusions: Although initially known for its respiratory manifestations, it has become evident that SARS-CoV-2 not only infects pneumocytes but also enters the vascular endothelium, leading to endothelial dysfunction and hypercoagulability and - as shown in our case - large-vessel vasculitis, which may predispose patients to intramural haemorrhage and arterial dissection.

A Systematic Review of Arterial Dissections in COVID-19 Patients

INTRODUCTION

COVID-19 is often seen presenting with a myriad of signs and symptoms of multiorgan dysfunction including arterial dissection.

METHODS

Various theories have been proposed such as endothelial dysfunction triggered by hyperinflammatory response that results in rupture of atherosclerotic plaque and subsequent dissection.

RESULTS

However, the exact incidence is unknown and only case reports and case series have been published till date.

CONCLUSION

Here we carried out a systematic analysis of published case reports/series related to dissection of the aorta, coronary, cerebral, vertebral, cervical, renal, and splanchnic arteries.