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.

1. Spontaneous Coronary Artery Dissection in a Pre- Menopausal
Woman Occurring Just prior to Menstruation

2. 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.
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3. 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
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4. 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.
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