ABC | Volume 112, Nº4, April 2019

Case Report Spontaneous Coronary Artery Dissection - Case Report and Literature Review Elana Couto de Alencar Danie l and João Luiz de Alencar Araripe Falcão Hospital Dr. Carlos Alberto Studart Gomes de Messejana, Messejana, Fortaleza, PE – Brazil Mailing Address: Elana Couto de Alencar Daniel • Rua Tomás Acioli, 840/ 403. Postal Code 60135-180, Joaquim Távora, Fortaleza, CE – Brasil E-mail: elana.alencar@gmail.com Manuscript Received March 28, 2018, revised manuscript July 19, 2018, accepted August 15, 2018 Keywords Acute Coronary Syndrome; Dissection; Chest Pain; Percutaneous Coronary Intervention; Cardiac Catheterization. DOI: 10.5935/abc.20190057 Introduction We report three cases of spontaneous coronary artery dissection (SCAD), with literature review and discussion of the procedures employed. All of them occurred in women, with the diagnosis being made by coronary angiography and, in one case, confirmed by intravascular ultrasound (IVUS). 1 st Case The patient was 25 years old, with no risk factors for cardiovascular disease (CVD), hospitalized with typical chest pain, elevated cardiac enzymes and electrocardiogram (ECG) with diffuse ST-depression and ST-segment elevation in aVR, underwent cardiac catheterization (CC), which disclosed moderate lesion in the left main coronary artery (LMCA), severe lesion in the proximal third of the anterior descending artery (ADA) and parietal irregularities in the circumflex artery (Cx) (Figure 1). Transthoracic echocardiogram (TTE) showed mid-apical hypokinesia of the anterior, inferolateral walls and small apical areas, with preserved biventricular systolic function. The patient was submitted to an IVUS that showed aspect compatible with intramural hematoma from the DA ostium to the first diagonal artery, and spontaneous dissection/hematoma from the proximal third of the Cx to the distal third of the first left marginal artery (image not available). Clinical treatment was chosen with excellent response. During outpatient follow-up, she remained asymptomatic. An angiographic restudy was performed six months after the event, showing significant obstruction improvement (Figure 1). 2 nd Case The patient was 41 years old with hypertension, hypothyroidism and was an ex-smoker, having delivered a child six months before. She sought the emergency service with typical chest pain triggered by emotional stress and ECG showing +/- in the high lateral wall. She was referred to CC, which showed moderate lesion in the middle third of the ADA and moderate/severe lesion in the distal third, suggestive of SCAD. The TTE showed no alterations. Clinical treatment was chosen. Angiographic restudy three months after the event showed persistence of moderate obstruction in the middle third of the ADA, with obstruction resolution in the distal third. At the time, stent implantation was performed in the middle third of the ADA. The procedure showed no complications and was successful (Figure 2). 3 rd Case The patient was 51 years old, with no risk factors for CVD, hospitalized with typical chest pain and elevated cardiac enzymes. The ECG showed no alterations. She was referred to the hemodynamics service, and a severe lesion was disclosed in the distal third of the first left marginal artery, with a pattern suggestive of SCAD. The TTE showed moderate hypokinesia of the left ventricular inferior-lateral, with preserved biventricular systolic function. She received clinical treatment with good response to therapy (Figure 3). Discussion In 1931, Pretty first described SCAD during the autopsy of a 42-year-old woman who had sudden death after reporting chest pain.¹ With the onset of the invasive approach to acute coronary syndrome (ACS), the number of diagnosed cases increased. Nevertheless, it is still believed that this diagnosis may be underestimated.² SCAD is a rare cause of ACS, with an incidence of 0.1 to 4.0%.³ The clinical presentation ranges from unstable angina to sudden death, often being undiagnosed. It mainly affects young women with no classic CVD risk factors. 4 In the reported cases, all of them are young women, two of which did not have CVD risk factors. The following are described as events that may be related to SCAD: peripartum status, connective tissue diseases, vasculitis, cocaine abuse, heavy isometric exercise and use of oral contraceptives. 5 The most frequently affected artery is the ADA, in 75% of cases, followed by the right coronary artery, in 20% of the patients; the Cx, in 4%, and finally the LCMA, in less than 1% of the cases. 6 Among the three reported cases, two had the ADA as the main affected artery, which corroborates with data found in the literature. The pathogenesis of SCAD has yet to be fully elucidated. It is known that the main factors responsible for spontaneous dissection are the arterial wall weakening and increased shear forces.³ It is postulated that the primary rupture of the vasa vasorum occurs, leading to hemorrhage and consequent separation of the coronary artery wall layers, creating a false lumen between the intima and media layers of the vascular wall. 7 473