ABC | Volume 113, Nº5, November 2019

Viewpoint Spontaneous Exercise-Related Coronary Artery Dissection among Young Patients Without Risk Factors or Atherosclerotic Disease Pablo de Souza 1, 2 and Artur Haddad Herdy 1, 2 Instituto de Cardiologia de Santa Catarina (ICSC), 1 São José, SC – Brazil Clínica Cardiosport de Prevenção e Reabilitação, 2 Florianópolis, SC – Brazil Mailing Address: Pablo de Souza • Clínica Cardiosport - Rua Ernesto Stodieck, 56. Postal Code 88025-130, Centro, Florianópolis, SC – Brazil E-mail: pablocardiologia@gmail.com Manuscript received December 26, 2018, revised manuscript January 25, 2019, accepted July 17, 2019 Keywords Coronary Artery Disease; Myocardial Infarction; Death, Sudden, Cardiac; Young Adult; Risk Factors; Physical Exertion; Exercise; Diagnostic, Imaging/trends. DOI: https://doi.org/10.36660/abc.20180446 Abstract Spontaneous coronary artery dissection (SCAD) is considered an often underdiagnosed acute coronary syndrome, with few cases described in literature. Its associationwith physical exercise among young patients without risk factors or atherosclerotic disease (CAD) is even rarer. For this reason, a study was conducted on the subject, describing the clinical conditions, conduct and evolution regarding the suspicion of spontaneous exercise-related coronary artery dissection in three young patients without risk factors or CAD. Clinical conditions varied, with predominant recurrent chest pain. Age range from 20 to 31 years. All patients underwent coronary angiography, which showed no CAD but suggested SCAD. Investigations concerning other causes of coronary obstruction were negative. The right coronary artery was affected in two cases, and the anterior descending artery was affected in one case. Only one of the three patients had recurrent events within five years from the primary event. Technological advances will enable increased dissection identification in acute coronary syndromes. Improving the knowledge about the related clinical conditions is necessary, as an attempt to provide warnings and improve the suspicion of spontaneous exercise-related coronary artery dissection among those who have symptoms of coronary insufficiency, thus reducing the frequent underdiagnosis. The best treatment and prognosis for this disease remains uncertain. Introduction Often underdiagnosed in its history, spontaneous coronary artery dissection (SCAD) has been described as a rare etiology among acute coronary syndrome (ACS). 1-4 Although it has been poorly studied, SCAD can result in significant morbidity, leading to ischemia and acute myocardial infarction (AMI), as well as ventricular arrhythmias and sudden cardiac death. 1-3,5-7 SCAD cases are common in literature as isolated cases, 1,4-8 and generally, this disease affects young women that had late diagnosis shown in a necropsy as registered in most publications. The first case described was in 1931. 1,2,9-12 Recently, more cases of SCAD have been identified due to routine coronary angiography in ACS and technological advances in imaging. 1 SCAD is associated with heterogeneous pathophysiological situations, 13,14 as atherosclerotic disease (CAD), peripartum period, collagen diseases, genetic vasculopathies, cocaine and amphetamine abuse, anabolic and corticosteroid use, severe systemic hypertension, oral contraceptives, fibromuscular dysplasia, vasospasm and physical exercise. 1,2,13-22 Physiologically, SCADis definedas a separationof non‑iatrogenic or traumatic coronary artery layers, creating a false lumen. 1-4,7 This fragmentationcanoccur between the intimal andmiddle layers or between themiddle and adventitial layers, with the formationof a intramural hematoma in the arterywall that compresses the artery lumen, reducing the anterograde blood flow with a subsequent ischemia or AMI. 1‑4 In some cases, a hematomamay communicate with the vessel lumen and a consequent thrombus formation at the endothelial lesion site. In addition, the possibility of endothelial injury caused by mechanical stress is speculated at some point in the vessel, leading to thrombosis at this site. 1,2,7-22 There are few cases that associate SCADwith sports physical activities among young male patients without risk factors or CAD. 17-20 In the present study, we describe three cases of ACS among young patients without risk factors and established or underdiagnosed CAD, where the main etiological suspicion of coronary artery flow obstruction was SCAD related to intense physical exercise, as concluded by the initial presentations, the complementary exams and the clinical evolution, considering the probable pathophysiological mechanism involved. The three cases presented were similar among each other. Methods Three young male patients without risk factors and CAD who had symptoms of coronary insufficiency during or after intense physical exercise were evaluated. Outpatient or emergency investigations suggested SCAD. The morbidity history of the patients was analyzed, excluding risk factors such as systemic arterial hypertension, smoking, use of drugs, anabolic steroids, ergogenic drugs, anorectic or illicit drugs, positive family history for coronary heart disease, cardiomyopathies or thrombotic disease. Cardiac catheterization (CATE) revealed a large amount of intracoronary thrombus, unrelated to CAD, suggesting SCAD as the main diagnostic hypothesis. We also researched and disregarded coagulation disorders after the occurrence of acute events. Table 1 presents the serial markers for thrombophilia, rheumatology diseases, inflamatory diseases, and connective tissue and negative serology researched in three patients. 988