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Spontaneous coronary artery dissection undissolved using cardiac computed tomography
International Journal of Cardiology 222 (2016) 1040–1041
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Spontaneous coronary artery dissection undissolved using cardiac computed tomography Becker S.N. Alzand MD, FESC, FACC a,c,⁎, Laurent Vanneste MD a, Didier Fonck MD b, Carlos Van Mieghem MD, PhD c a b c
Department of Cardiology, Glorieux General Hospital, Ronse, Belgium Department of Radiology, Glorieux General Hospital, Ronse, Belgium Department of Cardiology, Onze Lieve Vrouw General Hospital, Aalst, Belgium
a r t i c l e
i n f o
Article history: Received 20 June 2016 Accepted 3 August 2016 Available online 06 August 2016
A previously healthy 34-year-old female was referred to our department with abrupt syncope preceded by chest discomfort. She has no cardiovascular risk factors. She is a mother of 10 and gave birth to her youngest son 4 months ago. She was admitted in our department for further investigation. Electrocardiogram (ECG) and Echocardiogram were normal. Cardiac CT (CCT) revealed a calcium Agatston score of 0 with no detectable coronary abnormalities (Fig. 1, Movie 1). She was discharged 24 h later as the cardiac enzymes remained normal and no rhythm disturbance was present during monitoring. 3 days later she visited her general practitioner with the same symptoms. In his clinic she collapsed due to ventricular fibrillation and was successfully resuscitated. ECG was compatible with an acute inferior wall myocardial infarction. Coronary angiography showed a spontaneous coronary artery dissection (SCAD) of the right coronary artery (Fig. 1, Movie 2). Coronary stenting was performed and she was discharged with excellent neurological recovery after a short period of rehabilitation. SCAD is a rare condition occurs predominantly in young women. The annual incidence is estimated to be 0.26/100,000 persons [1]. The majority of Initial reports were diagnosed by autopsy with the left anterior descending artery being the most reported location. Though the exact pathophysiology is not fully understood, hormonal, vascular, or shear stress-related factors appear to be the major triggers. Extreme physical activity is the principal trigger in men. Postpartum status seems to be the most common associated factor in women. Fibromuscular dysplasia was incidentally found in 50% of patients [1]. The recurrence rate is high and is up to 29.4% in 10 years [1]. Recognition of SCAD is difficult. Coronary angiography is the most appropriate technique although frequently overlooked until after death [2]. Clinical suspicion and multiple angiographic views are required. Intravascular ultrasound provides detailed imaging of the intimal flap and it's circumferential and longitudinal spatial distribution [2]. The use of CCT in SCAT has been reported to establish a post-mortem diagnosis or to provide
http://dx.doi.org/10.1016/j.ijcard.2016.08.058 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
additional information on the extension of the intramural haematoma and the intimal flap when performed after coronary angiography. No data are available on CCT as an initial diagnostic tool. As in our case, CCT seems to be inappropriate in early stages with confined intimal flap and intermittent intraluminal protrusion. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2016.08.058.
Fig. 1. Coronary angiographic and CT images of the right coronary artery. Cross-sectional, volume rendering and longitudinal Cardiac CT images showing a normal right coronary artery with no signs of any dissection flap probably due to low spatial resolution and/or intermittent protrusion. Coronary angiography 3 days later shows spontaneous right coronary artery dissection.
B.S.N. Alzand et al. / International Journal of Cardiology 222 (2016) 1040–1041
1041
Conflict of interest
References
All authors have read and approved the manuscript, and no part of this manuscript is being published or under consideration for publication elsewhere. There are no conflicts of interest for any of the authors.
[1] M.S. Tweet, S.N. Hayes, S.R. Pitta, R.D. Simari, A. Lerman, R.J. Lennon, B.J. Gersh, S. Khambatta, P.J.M. Best, C.S. Rihal, R. Gulati, Clinical features, management and prognosis of spontaneous coronary artery dissection, Circulation 126 (2012) 579–588. [2] F. Alfonso, Spontaneous coronary artery dissection: new insights from the tip of the iceberg? Circulation 126 (2012) 667–670.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Spontaneous coronary artery dissection undissolved using cardiac computed tomography Becker S.N. Alzand MD, FESC, FACC a,c,⁎, Laurent Vanneste MD a, Didier Fonck MD b, Carlos Van Mieghem MD, PhD c a b c
Department of Cardiology, Glorieux General Hospital, Ronse, Belgium Department of Radiology, Glorieux General Hospital, Ronse, Belgium Department of Cardiology, Onze Lieve Vrouw General Hospital, Aalst, Belgium
a r t i c l e
i n f o
Article history: Received 20 June 2016 Accepted 3 August 2016 Available online 06 August 2016
A previously healthy 34-year-old female was referred to our department with abrupt syncope preceded by chest discomfort. She has no cardiovascular risk factors. She is a mother of 10 and gave birth to her youngest son 4 months ago. She was admitted in our department for further investigation. Electrocardiogram (ECG) and Echocardiogram were normal. Cardiac CT (CCT) revealed a calcium Agatston score of 0 with no detectable coronary abnormalities (Fig. 1, Movie 1). She was discharged 24 h later as the cardiac enzymes remained normal and no rhythm disturbance was present during monitoring. 3 days later she visited her general practitioner with the same symptoms. In his clinic she collapsed due to ventricular fibrillation and was successfully resuscitated. ECG was compatible with an acute inferior wall myocardial infarction. Coronary angiography showed a spontaneous coronary artery dissection (SCAD) of the right coronary artery (Fig. 1, Movie 2). Coronary stenting was performed and she was discharged with excellent neurological recovery after a short period of rehabilitation. SCAD is a rare condition occurs predominantly in young women. The annual incidence is estimated to be 0.26/100,000 persons [1]. The majority of Initial reports were diagnosed by autopsy with the left anterior descending artery being the most reported location. Though the exact pathophysiology is not fully understood, hormonal, vascular, or shear stress-related factors appear to be the major triggers. Extreme physical activity is the principal trigger in men. Postpartum status seems to be the most common associated factor in women. Fibromuscular dysplasia was incidentally found in 50% of patients [1]. The recurrence rate is high and is up to 29.4% in 10 years [1]. Recognition of SCAD is difficult. Coronary angiography is the most appropriate technique although frequently overlooked until after death [2]. Clinical suspicion and multiple angiographic views are required. Intravascular ultrasound provides detailed imaging of the intimal flap and it's circumferential and longitudinal spatial distribution [2]. The use of CCT in SCAT has been reported to establish a post-mortem diagnosis or to provide
http://dx.doi.org/10.1016/j.ijcard.2016.08.058 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
additional information on the extension of the intramural haematoma and the intimal flap when performed after coronary angiography. No data are available on CCT as an initial diagnostic tool. As in our case, CCT seems to be inappropriate in early stages with confined intimal flap and intermittent intraluminal protrusion. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2016.08.058.
Fig. 1. Coronary angiographic and CT images of the right coronary artery. Cross-sectional, volume rendering and longitudinal Cardiac CT images showing a normal right coronary artery with no signs of any dissection flap probably due to low spatial resolution and/or intermittent protrusion. Coronary angiography 3 days later shows spontaneous right coronary artery dissection.
B.S.N. Alzand et al. / International Journal of Cardiology 222 (2016) 1040–1041
1041
Conflict of interest
References
All authors have read and approved the manuscript, and no part of this manuscript is being published or under consideration for publication elsewhere. There are no conflicts of interest for any of the authors.
[1] M.S. Tweet, S.N. Hayes, S.R. Pitta, R.D. Simari, A. Lerman, R.J. Lennon, B.J. Gersh, S. Khambatta, P.J.M. Best, C.S. Rihal, R. Gulati, Clinical features, management and prognosis of spontaneous coronary artery dissection, Circulation 126 (2012) 579–588. [2] F. Alfonso, Spontaneous coronary artery dissection: new insights from the tip of the iceberg? Circulation 126 (2012) 667–670.