Clinical Pearls & Morning Reports
Published December 20, 2017
Spontaneous coronary-artery dissection should be a strong consideration in a young woman or man who does not have traditional cardiac risk factors and who presents with an acute coronary syndrome. Read the latest Case Record of the Massachussetts General Hospital.
Q: What are some of the risk factors for spontaneous coronary-artery dissection?
A: Certain hormonal influences are thought to increase the risk of spontaneous coronary-artery dissection, because many patients receive the diagnosis during either late pregnancy or the early postpartum period. Other risk factors for spontaneous coronary-artery dissection include intense physical activity, emotional stress, fibromuscular dysplasia, and systemic inflammatory conditions. Genetic diagnoses associated with spontaneous coronary-artery dissection include Marfan’s syndrome, the Loeys–Dietz syndrome, vascular Ehlers–Danlos syndrome, autosomal dominant polycystic kidney disease, and probably others.
Q: Is coronary angiography always performed for the diagnosis of spontaneous coronary-artery dissection?
A: In patients who are hemodynamically stable and have improving or resolved chest pain, the diagnosis of spontaneous coronary-artery dissection can be made with the use of cardiac computed tomographic (CT) angiography. In patients with unremitting chest pain or in those who have nondiagnostic results on cardiac CT angiography, invasive coronary angiography is often performed, but there is a risk that introduction of the catheter into the coronary artery will propagate the dissection.
A: Coronary-artery dissection is frequently associated with the presence of excessive tortuosity of the coronary arteries. Distinct subtypes of spontaneous coronary-artery dissection have been described. Type 1 dissection is associated with a characteristic staining pattern within the vessel wall that is consistent with intimal disruption. Type 2 dissection is characterized by a diffuse, smooth pattern of luminal narrowing. Type 3 dissection, which mimics atherosclerosis, is associated with focal segments of luminal narrowing. Type 3 dissection is uncommon, and intravascular ultrasonography or optical coherence tomography may be performed to establish the diagnosis with certainty.
A: After a coronary-artery dissection has been identified on coronary angiography, a conservative approach is typically warranted, particularly in the presence of preserved distal perfusion. Placement of a guidewire for percutaneous coronary intervention can be technically difficult and can lead to abrupt vessel closure or propagation of the dissection. Currently, few data support the use of antiatherosclerotic medications in the management of spontaneous coronary-artery dissection. Most experienced clinicians support the use of low-dose aspirin (80 to 100 mg daily) in all patients with spontaneous coronary-artery dissection and the use of dual antiplatelet therapy in those who undergo percutaneous coronary intervention; thrombolytic therapy, long-term therapy with heparin, and therapy with glycoprotein IIb/IIIa inhibitors are otherwise typically avoided. Beta-blockers and angiotensin-converting–enzyme inhibitors may be used selectively in patients with ongoing angina or heart failure. Patients with spontaneous coronary-artery dissection are usually referred for cardiac rehabilitation. Unique cardiac-rehabilitation programs have been designed for this typically fit, young group of patients. Because there is a frequent association between spontaneous coronary-artery dissection and fibromuscular dysplasia, CT angiography of the head, neck, abdomen, and pelvis is recommended. Genetic testing may be performed when there is a family history of possible connective-tissue disorders or evidence of connective-tissue disorders on physical examination or vascular screening; it may also be performed at the patient’s request.