Spontaneous coronary artery dissection: from expert consensus statements to evidence-based medicine

Simultaneous Takotsubo syndrome and spontaneous coronary artery dissection: a case report

A 59-year-old woman presented to the emergency room with sudden onset of retrosternal thoracic pain following emotional stress. The electrocardiogram (ECG) revealed T-wave inversions on precordial leads. Her blood analyses demonstrated elevation of myocardial necrosis markers (peak of troponin I of 3.4 ng/ml). Transthoracic echocardiogram (TTE) findings were consistent with Takotsubo syndrome, accompanied by mild left ventricular dysfunction. The patient underwent invasive coronary angiography revealing a spontaneous coronary artery dissection in the left anterior descending artery and left main artery. A repeat TTE one week later showed complete resolution of the segmental contractility with a full recovery of left ventricular function. Cardiac magnetic resonance imaging revealed no abnormalities. The patient was discharged on dual-antiplatelet therapy. A follow-up coronary angiography performed one month later confirmed complete resolution of the dissection. Takotsubo syndrome and spontaneous coronary artery dissection predominantly affect women and share common triggers. This case highlights the often misdiagnosed association and emphasises the specific diagnosis and treatment nuances associated with it.

Conservative Management of Spontaneous Left Main Coronary Artery Dissection (SCAD) Triggered by Emotional Stress in the Late Postpartum Period: Case Report and Pathophysiology

A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability.

Optical coherence tomography: fundamentals and clinical utility

Although coronary angiography is the standard method employed to assess the severity of coronary artery disease and to guide treatment strategies, it provides only 2D image of the intravascular lesions. In contrast, intravascular imaging modalities such as optical coherence tomography (OCT) produce cross-sectional images of the coronary arteries at a far greater spatial resolution, capable of accurately determining vessel size as well as plaque morphology, eliminating many of the disadvantages inherent to angiography. This review will discuss the role of OCT in the catherization laboratory for the assessment and management of coronary disease.

A 'parachute effect' mockingly sealing a spontaneous coronary artery dissection: what we have learnt from intravascular imaging

Spontaneous coronary artery dissection is often underdiagnosed. It accounts for a certain amount of acute coronary syndromes. Intravascular imaging, either intravascular ultrasound or optical coherence tomography, represents a relevant ally for interventional cardiologist. Here we report an intriguing case of spontaneous coronary artery dissection not immediately diagnosed due to the explained parachute effect, managed invasively according to an algorithm previously published, with a good long-term outcome.

Spontaneous coronary artery dissection in systemic lupus erythematosus: case-based review

Patients with systemic lupus erythematosus (SLE) present an increased prevalence of coronary heart disease. The majority of cases of acute coronary syndrome (ACS) in patients with SLE are due to atherosclerosis. Less common causes include thrombosis of an angiographically normal coronary artery and coronary vasculitis. Spontaneous coronary artery dissection (SCAD) is a rare cause of ACS in these patients. We report the case of a 53-year-old female diagnosed of SLE presenting with an ACS caused by SCAD. She was treated medically and her clinical course was favorable. A literature search identified seven additional cases of SCAD associated with SLE. The main clinical features found in these reports are revised. ACS caused by SCAD in SLE patients is a condition likely under-reported in literature. SCAD should be suspected in patients with SLE and ACS, especially in younger women without evident cardiovascular risk factors. An early accurate diagnosis of SCAD is key to provide specific treatment, which differs from that of usual atherosclerotic ACS.