Approaches for the treatment of spontaneous coronary artery dissection: A case review

Spontaneous coronary artery dissection (SCAD) is a tear in the wall of the epicardial coronary artery that is not caused by trauma, coronary intervention, or atherosclerotic plaque rupture. Diagnosis is made by coronary angiography, computed tomography coronary angiography (CTCA), intravascular ultrasound (IVUS) and optical coherence tomography (OCT). SCAD has been shown to be a rare cause of acute coronary syndrome and sudden cardiac death. The usual clinical presentation is a picture of acute myocardial infarction. Young women represent about 70% of patients and 30% of such cases are related to the peripartum period, due to hormonal changes. Left anterior descending (LAD) is the most common site of dissection which represents 60% cases. Right coronary artery (RCA) is the second most common site (more common in men), followed by the left main coronary artery. The treatment options for this event are conservative, interventional (PCI) or surgical (CABG). The conservative approach is suitable for low-risk stable patients, but in the presence of ongoing ischemia, cardiogenic shock or sustained ventricular tachycardia/fibrillation - an intervention should be performed. In this current article we will present two cases of SCAD which took a completely different path in regards of the treatment approach that was chosen. The first case is a 48-years old female who was admitted in cardiology department due to the chest pain and dynamic ECG changes. The coronary angiography revealed a SCAD in LAD, but due to the stable state of the patient we decided to go with conservative treatment. However, after 12 hours, the patient reported another episode of chest pain with the ECG showing ST-elevations in precordial leads. Due to the high complexity of the intervention we decided to refer the patient for operation. CABG was performed (LIMA-LAD) and the patient was discharged five days post operation. Our second case as a 46-years-old man presenting with ECG changes for inferior AMI. The angiography revealed a SCAD in RCA. Due to ongoing chest pain we decided to go for an interventional treatment - PCI was successfully performed with implantation of four drug-eluting stents. SCAD is a condition that can occur in everyday practice in patients with ACS and can be expected as the cause of ACS in young patients without significant risk factors. There is no universal principal regarding the treatment method, so rushing to perform an intervention (PCI or CABG) is not recommended, unless there is ongoing ischemia. In some of the cases, the dissection regenerates spontaneously, but in the acute phase, intervention or surgery is sometimes required.