Spontaneous coronary artery dissection as a cause of myocardial infarction: a review and clinical case

Abstract

Spontaneous coronary artery dissection (SCAD) is an acute dissection of the arterial wall with the formation of an intramural hematoma anywhere between its layers with the formation of a false and compression of the true lumen of the vessel, which is not iatrogenic and is not caused by aortic dissection, trauma, rupture or erosion of atherosclerotic plaque. The probable pathophysiological mechanisms of SCAD are rupture of the endothelial-intimal layer of the vessel with the subsequent formation of a subintimal hematoma or bleeding from the vasa vasorum, formation of a hematoma in the artery wall and its breakthrough into the true lumen without prior damage to the intima. SCAD develops more often in women than in men. Among the factors that can cause SCAD, fibromuscular dysplasia, systemic inflammatory diseases, congenital connective tissue diseases, nonspecific inflammatory bowel diseases and genetic predisposition are considered. The development of dissection can be provoked by significant physical exertion, emotional stress, and abuse of recreational substances with sympathomimetic activity. In more than 90 % of cases, DM causes myocardial infarction (MI) with ST segment elevation or MI without ST segment elevation. The primary diagnostic method of SCAD is invasive angiography.
The article presents a clinical case of managing a patient with MI caused by SCAD. In hemodynamically stable patients, conservative treatment tactics are considered more appropriate, i.e. the use of drug treatment without primary percutaneous coronary intervention. In patients with cardiogenic shock, life-threatening ventricular arrhythmias, recurrent signs of ischemia, or dissection in the left main coronary artery or proximal epicardial arteries, endovascular or surgical reperfusion techniques are recommended. Drug therapy for such patients includes beta-blockers, antiplatelet agents, and statins.