SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMAN OCCURRING JUST PRIOR TO MENSTRUATION
 

SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMAN OCCURRING JUST PRIOR TO MENSTRUATION

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SCAD is a rare presentation of acute coronary syndrome(ACS) and clinically indistinguishable from ...

SCAD is a rare presentation of acute coronary syndrome(ACS) and clinically indistinguishable from
plaque rupture. It predominantly affects young women with
no traditional cardiovascular risk factors, especially during
the post-partum and pre-menopausal period [1-3]. The
aetiology of SCAD is multifactorial and complex. Optimal
treatment strategy for SCAD is not clearely defined.

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SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMAN OCCURRING JUST PRIOR TO MENSTRUATION SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMAN OCCURRING JUST PRIOR TO MENSTRUATION Document Transcript

  • Spontaneous Coronary Artery Dissection in a Pre- Menopausal Woman Occurring Just prior to Menstruation
  • Case Report SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMAN OCCURRING JUST PRIOR TO MENSTRUATION Pradeepto Ghosh, Sunita Pillay, Sohail Khan and Anoop Chauhan Department of Cardiology, Lancashire Cardiac Centre, Blackpool, UK. Correspondence to: Dr Pradeepto Ghosh, Department of Cardiology, Lancashire Cardiac Centre, Blackpool, UK. Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction. It is known to occur in young women in the peripartum period. The exact aetiology is unknown. This report describes a 46 year old pre-menopausal woman without cardiac risk factors presenting with acute inferior myocardial infarction and SCAD angiographically. She was noted to be at the end of her menstrual cycle. We believe that her SCAD was directly related to the phase of menstrual cycle she was in. Key words: Spontaneous ceronary artery dissection, Myocardial infarction. Asthma. Repeat angiogram after six months revealed a totally healed RCA (Fig. 2). INTRODUCTION SCAD is a rare presentation of acute coronary syndrome(ACS) and clinically indistinguishable from plaque rupture. It predominantly affects young women with no traditional cardiovascular risk factors, especially during the post-partum and pre-menopausal period [1-3]. The aetiology of SCAD is multifactorial and complex. Optimal treatment strategy for SCAD is not clearely defined. DISCUSSION Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. It is typically described in healthy women with no evidence of coronary atherosclerosis [1-3]. SCAD is three times more likely to occur in women than in men and is often seen in the peripartum period. Two case series have found 22% cases to occur during delivery and 78% in the post partum period [1]. SCAD has also been associated with cocaine use, CASE REPORT A forty-six year old lady presented with atypical chest pain, . She had no history of hypertension, diabetes, family history of coronary artery disease, hyperlipaedemia or previous chest pain. She was on steroid inhalers and did not take oral contraceptives. She was a non smoker and occasionally took alcohol. She did not abuse drugs and had no personal or family history of Marfan syndrome, recent chest trauma or connective tissue disease. She had a regular 28 day cycle with 5 days of menstruation. She presented two days prior to starting her periods. Her admission electrocardiogram demonstrated ST elevation in inferior leads. She was normotensive. A diagnosis of acute ST elevation MI was made and she was successfully thrombolysed with reteplase and managed conservatively (aspirin, clopidogrel, low molecular weight heparin, and statin). Coronary angiogram done ten days later revealed dissection of distal right coronary artery (Fig.1). Left ventriculography revealed mild inferior hypokinesia and good LV function. As the patient had been completely pain free leading up to her angiogram, the decision was made to treat her conservatively, and she was discharged home on aspirin 75 mg daily, ramipril 5 mg daily and atorvastatin 10 mg daily. She was not given beta-blockers due to history of Apollo Medicine, Vol. 7, No. 1, March 2010 Fig.1. Coronary angiogram showing dissection in the distal right coronary artery. 58
  • Case Report coronary angiography series, the incidence of SCAD has been reported from 0.1% to 1.1% [2]. However, SCAD may elude diagnosis even with angiography: if an intimal tear is absent, the medial haematoma may appear as a narrowed or occluded vessel with coronary angiography. Hence, some advocate use of Intravascular Ultrasound [2]. The latter will distinguish atherosclerotic stenosis from intimal/medial haematoma [2]. CT angiography has 99% sensitivity and 96% specificity for detecting significant coronary stenosis, though the sensitivity for detection of coronary artery dissection is unknown [6]. While SCAD is well recognized as a rare cause of ACS, and sudden cardiac death, its optimal treatment is not established [1,6]. Stable patients with limited dissections frequently are candidates for medical treatment, involving beta blockade to reduce vascular shear forces and anti platelet agents to reduce thrombus formation [2]. The uneventful long-term survival of such cases treated conservatively has been reported [1,2]. Our case was managed conservatively within follow up angiography 7 months later showing complete resolution of SCAD.. Ongoing ischaemia refractory to medical management should prompt urgent revascularization [2]. Coronary artery bypass grafting should be reserved for patients with left main dissection, multi vessel dissection or failure of percutaneous interventional procedures [2]. Fig.2. Follow-up angiogram 6 months later shows complete healing of distal right coronary artery dissection following conservative management. hypertensive crisis, haemodialysis, sexual intercourse, sleep deprivation, physical exercise, oral contraceptive use and connective disorders [2]. Histologically there was a large haematoma occupying the outer third of the vessel media, causing luminal encroachment [2]. Other histopathological changes include smooth muscle cell proliferation and vacuolar and collagen degeneration, fibrosis and perivascular inflammatory infiltrate [3]. In conclusion, we feel that in patients of this age group (pre-menopausal) presenting with symptoms suggestive of coronary ischaemia, a menstrual history should be obtained and the diagnosis of SCAD should be considered. We also believe, that such patients who are clinically stable and have limited single vessel dissection, should be managed conservatively. No specific etiology has been described. Two cases have been reported where both women were found to be menstruating at the time of SCAD [3]. During menstruation the circulating levels of oestrogen and progesterone are at their lowest. In premanopausal women with variant angina, frequency of ischaemic episodes was highest from the end of the luteal phase to the beginning of the menstrual phase and was lowest in the follicular phase [4]. The suppressive effects of oestrogen, on vascular smooth muscle cell activity is described [5]. Moreover oestrogen is thought to have a direct atheroprotective effect through inhibition of growth regulatory factors [5]. It has been suggested that the loss of hormonal vascular smooth muscle cell suppression at the time of menstruation, may lead to an increase in smooth muscle activity with resultant weakness in the tunica media [3]. REFERENCES 1. Nishant Kalra, Jeff Greenblatt, Syed Ahmed. Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively. Int. Journal of Cardiology 2008; 129: e53-e55. 2. Jayanth Arnold, Nick West, William Gaal, et al. The role of intravascular ultrasound in the management of SCAD.Cardiovascular Ultrasound 2008; 6: 24. 3. Robert Slight, Ali Asgar Behranwala, Onyekwelu Nzewi, et al. Spontaneous coronary artery dissection: a report of two cases occurring during menstruation. The New Zealand Medical Journal 2003; 116: 1181. 4. H Kawano, TMotoyama, M Oghushi. Menstrual cycle variation of myocardial ischaemia in premanopausal women with variant angina. Ann Intern Med. 2001; 135(11):1002-1004. Unlike in the past early routine coronary angiography has made antemortem diagnosis of SCAD possible: the appearance of a radiolucent intimal flap or slow clearance of contrast from the false lumen [2]. In consecutive 5. Okubo T, Urabe M, Tsuchiya H, et al. Effect of oestrogen 59 Apollo Medicine, Vol. 7, No. 1, March 2010
  • Case Report and progesterone on gene expression of growth regulatory molecules and proto-oncogene in vascular smooth muscle cells. Endocr J 2000; 47:205-214. 6. Catherine Schroder, Robert C. Stoler, George B. Apollo Medicine, Vol. 7, No. 1, March 2010 Branning, et al. Postpartum multivessel spontaneous coronary artery dissection confirmed by coronary CT angiography. Baylor University Medical Center Proceedings; 19(4): 334-338. 60
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