Clinical Case of Spontaneous Dissection of Branches of The Left Coronary Artery in A Young Woman

Spontaneous coronary artery dissection (SСAD) is a rare but potentially dangerous cause of acute coronary syndrome, especially in young women without traditional risk factors for cardiovascular diseases. Etiological factors include fi bromuscular dysplasia, hereditary arteriopathies, systemic infl ammatory diseases, and hormonal changes. Despite the progress in diagnosis, the treatment of DMCA remains a diffi cult task due to the high variability of clinical manifestations and the lack of a single standard of therapy. The case of a young patient hospitalized with a ST-segment elevation myocardial infarction clinic, which occurred against the background of intense physical exertion, is presented. Coronary angiography (CAG) revealed spontaneous dissection of the branches of the left coronary artery. The progression of dissection was noted during CAH, which required repeated stenting and the use of mechanical circulatory support (VA-ECMO, IABC). Despite the treatment, the patient maintained unstable hemodynamics and the progression of multiple organ disfunction, which led to death. Histological examination revealed connective tissue dysplasia cannot be excluded, which could be a predisposing factor for the development of coronary artery dissection. Clinical recommendations suggest conservative management of stable patients, however, revascularization is indicated in the presence of complications such as cardiogenic shock. In this case, the invasive tactics did not affect the prognosis.

The above case demonstrates the complexity of diagnosis and management of patients with SDCA. Further research is needed to develop optimal treatment strategies and identify genetic markers predisposing to the development of this pathology.

1. Zainobidinov Sh.Sh., Khelimsky D.A., Baranov A.A. et al. Modern aspects of diagnosis and treatment of patients with spontaneous coronary artery dissection. Cardiovascular Therapy and Prevention. 2022;21(8):3193. https://doi.org/10.15829/1728-8800-2022-3193 [In Russian].

2. Kuznetsov A.A., Namitokov A.M., Sazhneva A.V. et al. Spontaneous left coronary artery dissection in the postpartum period: a case report. Russian Journal of Cardiology. 2022;27(3S):5059. https://doi.org/10.15829/1560-4071-2022-5059 [In Russian].

3. Golukhova E.Z., Abrosimov A.V., Losev V.V., et al. Endovascular treatment of a patient with spontaneous dissection of the right coronary artery. Angiology and Vascular Surgery. 2022;28(1):135-139. DOI: https:// doi.org/10.33029/1027-6661-2022-28-1-135-139 [In Russian].

4. Havakuk O, Goland S, Mehra A, et al. Pregnancy and the Risk of Spontaneous CoronaryArtery Dissection: An Analysis of 120 Contemporary Cases. Circ Cardiovasc Interv.2017;10(3):e004941. doi: 10.1161/CIRCINTERVENTIONS.117.004941

5. Saw J, Starovoytov A, Humphries K, et al. Canadian spontaneouscoronary artery dissection cohort study: in hospital and 30day outcomes. Eur Heart J. 2019;40(15):1188 97. doi: 10.1093/eurheartj/ehz007

6. Rogowski S, Maeder MT, Weilenmann D, et al. Spontaneous Coronary Artery Dissection: Angiographic FollowUp and LongTerm Clinical Outcome in a Predominantly Medically Treated Population. Catheterization and Cardiovascular Interventions. 2017;89(1):59–68. DOI: 10.1002/ccd.26383

7. Saw J, Aymong E, Sedlak T, Buller CE, et al. Spontaneous Coronary Artery Dissection: Association With Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes. Circulation: Cardiovascular Interventions. 2014;7(5):645–55. DOI: 10.1161/CIRCINTER-VENTIONS.114.001760

8. Nakashima T, Noguchi T, Haruta S, et al. Prognostic impact of spontaneous coronary artery dissection in young female patients with acute myocardial infarction: a report from the Angina Pectoris-Myocardial Infarction Multicenter Investigators in Japan. Int J Cardiol. 2016; 207: 341-348. doi: 10.1016/j.ijcard.2016.01.188

9. Saw J, Aymong E, Sedlak T, et al. Spontaneous Coronary Artery Dissection: Association With Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes. Circulation: Cardiovascular Interventions. 2014;7(5):645–55. DOI: 10.1161/CIRCINTER-VENTIONS.114.001760

10. Golukhova E.Z., Abrosimov A.V., Losev V.V. et al. Endovascular treatment of a patient with spontaneous dissection of the right coronary artery. Angiology and Vascular Surgery. 2022;28(1):135-139. DOI: https://doi.org/10.33029/1027-6661-2022-28-1-135-139 [In Russian].

11. Clinical practice guidelines for Acute ST-segment elevation myocardial infarction. Russian Journal of Cardiology. 2020;25(11):4103. doi: 10.15829/1560-4071-2020-4103 [In Russian].

12. Saw J. Coronary angiogram classification of spontaneous coronary artery dissection. Catheter Cardiovasc Interv. 2014 Dec 1;84(7):1115-22. doi: 10.1002/ccd.25293.).

13. Hayes SN, Tweet MS, Adlam D, et all. Spontaneous coronary artery dissection: JACC State-of-the-Art review. Journal of the American College of Cardiology. 2020; 76(8):961-84. DOI: 10.1016/j.jacc.2020.05.084

14. Trisvetova E.L. Modern concepts of fibromuscular dysplasia of the coronary arteries. Rational Pharmacotherapy in Cardiology 201 9;1 5(3):431 -438. DOI: 10.20996/1819-6446-2019-15-3-431-438 [In Russian].

15. Zhukova N.S., Shakhnovich R.M., Merkulova I.N. et al. Spontaneous Coronary Artery Dissection. Kardiologiia. 2019;59(9):52-63. https://doi.org/10.18087/cardio.2019.9.10269 [In Russian].

16. Clinical Guidelines. Guidelines for the Diagnosis and Treatment of Aortic Diseases (2017). Russian Journal of Cardiology and Cardiovascular Surgery. 2018;11(1):7-67. [In Russian].

17. Eniseeva ES, Protasov KV. Spontaneous coronary artery dissection: diagnosis and modern approaches to treatment. Siberian Medical Review. 2023; (5):12-22. DOI: 10.20333/25000136-2023-5-12-22 [In Russian].

18. Smirnova T.L., Gerasimova L.I. Clinical features of undifferentiated connective tissue dysplasia syndrome. Doctor.Ru. 2018;(8):40–44. DOI: 10.31550/1727-2378-2018-152-8-40-44 [In Russian].

19. Clinical guidelines of the Russian Scientific Medical Society of Internists for the diagnosis, treatment, and rehabilitation of patients with connective tissue dysplasia (first revision). Medical Bulletin of the North Caucasus. 2018;1–2(13):137–210. DOI: https://doi.org/10.14300/mnnc.2018.13037 [In Russian].

20. Smetanin M.Yu., Pimenov L.T., Chernyshova T.E. Hormonal profile and mineral metabolism indicators in women with connective tissue dysplasia. Practical Medicine. 2018;1(112):140–143. [In Russian].

21. Druk I.V., Nechaeva G.I., Oseeva O.V., et al. Personalized assessment of the risk of adverse cardiovascular events in young patients with connective tissue dysplasia. Kardiologiya. 2015;3:75–84 [In Russian].

22. Antonutti M, Baldan F, Lanera C, et al. Spontaneous coronary artery dissection: Role of prognostic markers and relationship with genetic analysis. Int J Cardiol. 2021 Mar 1;326:19-29. doi: 10.1016/j.ijcard.2020.10.040.

23. Kotecha D, Garcia-Guimaraes M, Premawardhana D, et all. Risks and benefits of percutaneous coronary intervention in spontaneous coronary artery dissection. 2021; 107(17):1398-1406. DOI: 10.1136/heartjnl-2020-318914

24. Kuznetsov A.A., Namitokov A.M., Sazhneva A.V. et al. Spontaneous left coronary artery dissection in the postpartum period: a case report. Russian Journal of Cardiology. 2022;27(3S):5059. https://doi.org/10.15829/1560-4071-2022-5059 [In Russian].