RESUMO
Resumen La disección espontánea de la arteria coronaria es una causa no aterosclerótica de infarto de miocardio, la cual es más común en mujeres jóvenes con pocos o ningún factor de riesgo cardiovascular. Es infrecuente, no se asocia a iatrogenia ni trauma, y se presenta por acumulación espontánea de sangre entre las capas de la pared arterial coronaria, por ruptura de la íntima; de ahí que genera una falsa luz que produce compresión externa del verdadero lumen arterial, con lo cual altera el flujo sanguíneo coronario y ocluye la arteria comprometida. Se expone el caso de una mujer de 31 años, sin factores de riesgo cardiovascular, quien ingresó a un servicio de urgencias con dolor torácico típico, de 2 horas de evolución. En el electrocardiograma se apreció elevación del segmento ST en las derivaciones de la cara anteroseptal e inferior, y troponina T de alta sensibilidad positiva, por lo que se realizó terapia trombolítica con tenecteplasa, sin obtener criterios de reperfusión. Se hizo angiografía coronaria, la cual mostró obstrucción total de la arteria coronaria descendente anterior en el tercio medio. El ultrasonido intravascular documentó flap de disección y hematoma en este segmento, los cuales confirmaron la disección coronaria espontánea. Se realizó angioplastia con implante de stent coronario y se restableció la circulación, observando mejoría de los síntomas.
Abstract Spontaneous coronary artery dissection is a non-atherosclerotic cause of myocardial infarction, more frequent in young women with few or no cardiovascular risk factors, it is infrequent, and it is not associated with iatrogenesis or trauma. It occurs due to spontaneous accumulation of blood between the layers of the coronary artery wall, due to rupture of the intima, generating a false lumen that produces external compression of the true arterial lumen, altering coronary blood flow, occluding the compromised artery. It is presented the case of a 31-year-old woman with no cardiovascular risk factors, who was admitted to an emergency department, with typical chest pain of 2 hours of evolution, showing ST-segment elevation in leads of anteroseptal and inferior face on the electrocardiogram and troponin T with high sensitivity positive. Therefore, thrombolytic therapy was performed with tenecteplase, without obtaining reperfusion criteria. Coronary angiography was performed that demonstrates total obstruction of the anterior descending coronary artery in the middle third. Intravascular ultrasound documents the dissection flap and hematoma in this segment that confirm spontaneous coronary dissection, performing angioplasty with implantation of a coronary stent, restoring circulation with improvement of symptoms.
RESUMO
Um homem de 28 anos com história pregressa de abuso de drogas foi encaminhado para coronariografia de emergência após parada cardíaca. O eletrocardiograma pós-ressuscitação mostrou elevação do segmento ST em V1-V4. A angiografia mostrou dissecção espontânea da artéria coronária, multiarterial e em diversos segmentos. Devido à instabilidade clínica, o paciente foi submetido à intervenção coronária percutânea da artéria descendente anterior. A prevalência da dissecção espontânea da artéria coronária como causa de síndrome coronariana aguda em homens é infrequente. No entanto, nos casos suspeitos, ela deve ser excluída. A parada cardiorrespiratória é um quadro incomum na dissecção espontânea da artéria coronária, e a intervenção coronária percutânea como modalidade terapêutica ainda é uma questão em debate.
A 28-year-old male with a previous history of drug abuse was sent to an emergent coronary angiography, after a cardiac arrest, with a post-resuscitation eletrocardiogram showing ST- segment elevation from V1-V4. Angiography showed multivessel and multisegment spontaneous coronary artery dissection. Due to clinical instability, patient underwent left anterior descending artery percutaneous coronary intervention. Prevalence of spontaneous coronary artery dissection as the cause of acute coronary syndrome is anecdotal in men. Yet, in the right scenarios as in this case, it must be ruled out. Cardiorespiratory arrest is an uncommon presentation of spontaneous coronary artery dissection and percutaneous coronary intervention in spontaneous coronary artery dissection is still a matter of debate.
RESUMO
Intramural coronary hematoma (IMCH) is a rare cause of acute myocardial infarction (MI). We aim to review the current knowledge and share our experience with the diagnosis and management of a patient presenting with traumatic IMCH leading to an acute ST-segment elevation MI. (Level of Difficulty: Intermediate.).
RESUMO
Resumen: El diagnóstico de disección coronaria espontánea como causa de síndrome coronario agudo ha aumentado desde el surgimiento de las técnicas de imagen intracoronaria. Aún así, continúa siendo una entidad subdiagnosticada. La evidencia en relación con el tratamiento es escasa, pero la conducta conservadora ha demostrado resultados favorables en pacientes seleccionados. Presentamos el caso de una paciente de 55 años en la que se diagnostica infarto de miocardio sin elevación del ST. En la cineangiocoronariografía se sospecha como mecanismo causal la disección coronaria espontánea, lo cual se confirma mediante ultrasonido intravascular. Se optó por un tratamiento conservador con buena evolución.
Summary: The diagnosis of spontaneous coronary artery dissection as a cause of acute coronary syndrome has increased since the arise of intravascular imaging techniques. However, it still remains an underdiagnosed entity. Evidence related to its management is scarce, but conservative strategies have shown favorable outcomes in selected patients. We present the case of a 55-year-old female patient who is diagnosed with a non-ST segment elevation myocardial infarction. Spontaneous coronary artery dissection is suspected in the coronary angiography and then confirmed by intravascular ultrasound. Conservative management was selected, with favorable clinical outcomes.
Resumo: O diagnóstico de dissecção coronariana espontânea como causa da síndrome coronariana aguda aumentou com o surgimento das técnicas de imagem intracoronariana. Apesar disso é uma entidade subdiagnosticada. A evidência sobre o tratamento é escassa, mas o tratamento conservador mostrou resultados favoráveis em pacientes selecionados. Apresentamos o caso de um paciente de 55 anos com diagnóstico de infarto do miocárdio sem supradesnivelamento do segmento ST. Suspeita-se de dissecção coronariana espontânea na angiografia, confirmada por ultrassonografia intravascular. Se optou por tratamento conservador com boa evolução.
RESUMO
Pregnancy-associated spontaneous coronary artery dissection (PASCAD) accounts for less than 5% of spontaneous coronary artery dissection cases and is comparatively more fulminant or clinically aggressive. Several factors associated with PASCAD include black ethnicity, multiparity, hypertension, advanced maternal age, and age at first childbirth. This atypical case highlights a preeclamptic patient presenting with an ST-segment elevation myocardial infarction in which multivessel dissection of both the left anterior descending and right coronary arteries were deemed co-culprit lesions for the index event.
Assuntos
Anomalias dos Vasos Coronários/etiologia , Pré-Eclâmpsia/diagnóstico , Doenças Vasculares/congênito , Adulto , Cineangiografia , Anomalias dos Vasos Coronários/diagnóstico , Anomalias dos Vasos Coronários/diagnóstico por imagem , Eletrocardiografia , Feminino , Humanos , Masculino , Pré-Eclâmpsia/patologia , Gravidez , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Doenças Vasculares/diagnóstico , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/etiologiaRESUMO
AIMS: We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. METHODS AND RESULTS: Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient. CONCLUSION: In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.
Assuntos
Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/terapia , Imagem Multimodal/métodos , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem , Resultado da Gravidez , Doenças Vasculares/congênito , Adulto , Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Anomalias dos Vasos Coronários/mortalidade , Bases de Dados Factuais , Feminino , Seguimentos , Idade Gestacional , Mortalidade Hospitalar , Humanos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/mortalidade , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/terapia , Estudos Retrospectivos , Medição de Risco , Estudos de Amostragem , Centros de Atenção Terciária , Ultrassonografia de Intervenção/métodos , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/mortalidade , Doenças Vasculares/terapiaRESUMO
Spontaneous coronary artery dissection is a rare condition that usually causes a coronary syndrome, but may also cause sudden death. It is more common in women and is associated with factors such as the peripartum period and oral contraceptive use. We report two cases. A 45-year-old woman with hepatitis C, presenting in the emergency room with angina. An intravascular ultrasound showed a dissecting hematoma involving the left, anterior descending and circumflex coronary arteries. She was initially managed with nitroglycerin, anticoagulation and anti-platelet drugs but due to persistence of symptoms, she required surgical revascularization. A 32-year-old woman presenting in the emergency room with angina. A coronary angiogram revealed a dissection of the anterior descending coronary artery. Eight days later an intravenous ultrasound showed a retrograde progression of the dissection and she was subjected to a surgical revascularization.
Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Doenças Vasculares/congênito , Anomalias dos Vasos Coronários/diagnóstico por imagem , Doenças Vasculares/cirurgia , Doenças Vasculares/diagnóstico por imagem , Angiografia Coronária , Anomalias dos Vasos Coronários/cirurgiaRESUMO
Background: A 43 year old woman presented with chest pain followed by cardiac arrest recovered after defibrillation. Coronary angiography revealed a narrowed anterior descending coronary artery but no intraluminal thrombi. Optic coherence tomography showed intramural hematoma and the patient was treated medically with aspirin, clopidogrel and atorvastatin. Two weeks later the pain recurred and coronary angiography revealed similar findings. After medical treatment with heparin followed by aspirin and clopidogrel she has remained stable.
Assuntos
Humanos , Feminino , Adulto , Doença das Coronárias/complicações , Doença das Coronárias/diagnóstico por imagem , Parada Cardíaca/etiologia , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Vasos Coronários/patologia , Tomografia de Coerência Óptica , Eletrocardiografia , Hematoma/etiologia , Hematoma/diagnóstico por imagemRESUMO
La disección coronaria espontánea es una rara causa de isquemia miocárdica. Pese a esto se ha descrito como la enfermedad coronaria no aterosclerótica más frecuente, por lo cual es fundamental su diagnóstico y reconocimiento en forma temprana. Presentamos el caso de una paciente joven con síndrome coronario agudo con elevación del segmento ST debido a disección coronaria espontánea. A continuación se realiza una breve revisión de los aspectos más relevantes de esta patología.
Assuntos
Humanos , Feminino , Adulto Jovem , Adulto , Síndrome Coronariana Aguda/etiologia , Síndrome Coronariana Aguda/terapia , IsquemiaRESUMO
BACKGROUND: The physical exercise consists of trainable physical abilities such as strength and endurance. It can be inferred that the individual cardiac patient is dependent on it as an associated therapy to the drug treatment for a rapid and lasting improvement of their overall clinical status. CASE PRESENTATION: The patient - with Spontaneous Coronary Artery Dissection Postpartum period - was subjected to 21 sessions of cardiac rehabilitation. A physical evaluation was performed, before and after the treatment period, for data collection: anthropometric values, flexibility, aerobic capacity and strength of grip. CONCLUSION: The patient had a positive response in aerobic capacity, flexibility and grip strength and the anthropometric values were kept in short term rehabilitation.