COVID-19-associated spontaneous coronary artery dissection: Difference between revisions
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'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]''' | '''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]''' | ||
{{CMG}}; {{AE}} {{RAB}} {{AyeshaFJ}} | {{CMG}}; {{AE}} {{Sara.Zand}} {{RAB}} {{AyeshaFJ}} | ||
{{SK}} Covid-19, cardiac manifestation, Spontaneous coronary artery dissection, SCAD, Atherosclerothic-spontaneous coronary artery dissection, A-SCAD, Non-atherosclerothic spontaneous coronary artery dissection, NA-SCAD | |||
==Overview== | ==Overview== | ||
Severe acute respiratory syndrome coronavirus 2 ([[SARS-CoV-2|SARS‐CoV‐2]]) is caused by novel [[coronavirus disease 2019 virus]] ([[COVID-19|COVID‐19]]). [[Cardiac]] manifestations and injury were identified in up to 20–28% of [[patients]]. [[Spontaneous coronary artery dissection]] ([[SCAD]]) | Severe acute respiratory syndrome coronavirus 2 ([[SARS-CoV-2|SARS‐CoV‐2]]) is caused by novel [[coronavirus disease 2019 virus]] ([[COVID-19|COVID‐19]]). [[Cardiac]] manifestations and injury were identified in up to 20–28% of [[patients]]. [[Spontaneous coronary artery dissection]] ([[SCAD]]) is one of the [[cardiac]] complication of [[covid-19]] and can be either [[atherosclerotic]] or non-[[atherosclerotic]] resulting from attaching [[covid-19]] to [[ACE]] receptos of [[vessles]] wall and producing intense [[inflammation]] and [[endothelial dysfunction]], [[sympathetic over-reactivity]] that are the precursors of [[intimal dissection]]. [[SCAD]] can be manifested as [[STEMI]] or [[NSTEMI]] in [[patients]] with [[covid-19]] in which high clinical suspicion is warranted before administration of [[fibrinolysis]] in such [[patients]]. Among nine reported cases of [[covid-19]] associated [[SCAD]] there were not found any previous conventional risk factors of [[SCAD]] such as [[fibromuscular disease]], steraneous [[physical exercise]], [[ sex hormone]], or [[peripartum period]], except one case reported after intense [[cough]] in hospitalized [[covid-19]] [[patients]]. In reported [[covid-19]] [[patients]] associated with [[SCAD]], it was more common in [[men]] and all nine cases were survived with consevative therapy or [[percutaneous coronary intervention]] based upon the anatomical site of [[dissection]]. | ||
conventional risk factors of [[SCAD]] such as [[fibromuscular disease]], steraneous [[physical exercise]], [[ sex hormone]], or [[peripartum period]], except one case reported after intense [[cough]] in hospitalized [[covid-19]] [[patients]]. In reported [[covid-19]] [[patients]] associated with [[SCAD]], it was more common in [[men]] and all nine cases were survived with consevative therapy or [[percutaneous coronary intervention]] based upon the anatomical site of [[dissection]]. | |||
==Historical Perspective== | ==Historical Perspective== | ||
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==Pathophysiology== | ==Pathophysiology== | ||
*[[Spontaneous coronary artery dissection|SCAD]] can be secondary to an [[Atherosclerosis|atherosclerotic]] (A-[[SCAD]]) or non-[[atherosclerotic]] (NA-[[SCAD]]) lesion in origin. | |||
* Lessons from the previous [[coronavirus]] and [[influenza]] [[Epidemic|epidemics]] suggest that these viral infections can trigger [[Acute coronary syndromes|acute coronary syndrome]] primarily owing to a combination of a significant systemic [[inflammatory response]] plus localized [[vascular]] inflammation at the arterial [[plaque]] level. | |||
====Phathophysiology of [[SCAD]] in [[covid-19]] [[patients]]==== | |||
* The exact pathogenesis of [[spontaneous coronary artery dissection]] in [[covid-19]] [[patients]] is not fully understood. | * The exact pathogenesis of [[spontaneous coronary artery dissection]] in [[covid-19]] [[patients]] is not fully understood. | ||
* It is thought that [[SCAD]] in [[covid-19]] [[patients]] is the result of either Intense [[inflammation]] and [[endothelial dysfunction]] causing [[sympathetic overreactivity]] leading to [[intimal dissection]]. | * It is thought that [[SCAD]] in [[covid-19]] [[patients]] is the result of either Intense [[inflammation]] and [[endothelial dysfunction]] causing [[sympathetic overreactivity]] leading to [[intimal dissection]]. | ||
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* Transition of [[inflammatory]] cell via [[vasavasarum]] to the [[medial ]] and [[adventitial layer]]s of the [[vessels]] may lead to rupture of [[vasavasarum]]. | * Transition of [[inflammatory]] cell via [[vasavasarum]] to the [[medial ]] and [[adventitial layer]]s of the [[vessels]] may lead to rupture of [[vasavasarum]]. | ||
* [[Covid-19]] may attach to [[ACE]] receptors on [[endothelial]] and [[smooth muscle]] of [[coronary artery]] leading to [[inflammation]] in the muscle wall, massive death of [[endotheliocytes]], [[vascular tone]] impairment, [[hemostatic impairment]], and vulnerability of [[vessels]] wall to [[dissection]]. | * [[Covid-19]] may attach to [[ACE]] receptors on [[endothelial]] and [[smooth muscle]] of [[coronary artery]] leading to [[inflammation]] in the muscle wall, massive death of [[endotheliocytes]], [[vascular tone]] impairment, [[hemostatic impairment]], and vulnerability of [[vessels]] wall to [[dissection]]. | ||
====[[Atherosclerotic]]-[[Spontaneous Coronary Artery Dissection]] (A-[[SCAD]]) :==== | ====[[Atherosclerotic]]-[[Spontaneous Coronary Artery Dissection]] (A-[[SCAD]]) :==== | ||
*[[Coronary artery dissection]] may be related to intraplaque [[hemorrhage]] resulting in an intra-adventitial [[hematoma]], which can spread longitudinally along the [[coronary artery]], dissecting the tunicae.<ref name="CourandHarbaoui2020">{{cite journal|last1=Courand|first1=Pierre-Yves|last2=Harbaoui|first2=Brahim|last3=Bonnet|first3=Marc|last4=Lantelme|first4=Pierre|title=Spontaneous Coronary Artery Dissection in a Patient With COVID-19|journal=JACC: Cardiovascular Interventions|volume=13|issue=12|year=2020|pages=e107–e108|issn=19368798|doi=10.1016/j.jcin.2020.04.006}}</ref><ref name="SawMancini20162">{{cite journal|last1=Saw|first1=Jacqueline|last2=Mancini|first2=G.B. John|last3=Humphries|first3=Karin H.|title=Contemporary Review on Spontaneous Coronary Artery Dissection|journal=Journal of the American College of Cardiology|volume=68|issue=3|year=2016|pages=297–312|issn=07351097|doi=10.1016/j.jacc.2016.05.034}}</ref> | *[[Coronary artery dissection]] may be related to intraplaque [[hemorrhage]] resulting in an intra-adventitial [[hematoma]], which can spread longitudinally along the [[coronary artery]], dissecting the tunicae.<ref name="CourandHarbaoui2020">{{cite journal|last1=Courand|first1=Pierre-Yves|last2=Harbaoui|first2=Brahim|last3=Bonnet|first3=Marc|last4=Lantelme|first4=Pierre|title=Spontaneous Coronary Artery Dissection in a Patient With COVID-19|journal=JACC: Cardiovascular Interventions|volume=13|issue=12|year=2020|pages=e107–e108|issn=19368798|doi=10.1016/j.jcin.2020.04.006}}</ref><ref name="SawMancini20162">{{cite journal|last1=Saw|first1=Jacqueline|last2=Mancini|first2=G.B. John|last3=Humphries|first3=Karin H.|title=Contemporary Review on Spontaneous Coronary Artery Dissection|journal=Journal of the American College of Cardiology|volume=68|issue=3|year=2016|pages=297–312|issn=07351097|doi=10.1016/j.jacc.2016.05.034}}</ref> | ||
*In COVID-19 patients, due to high [[inflammatory]] load, a localized [[inflammation]] of the coronary [[adventitia]] and periadventitial fat can occur. This can lead to the development of sudden coronary artery [[Dissection (medical)|dissection]] in a susceptible patient with underlying [[cardiovascular disease]].<br /> | *In COVID-19 patients, due to high [[inflammatory]] load, a localized [[inflammation]] of the coronary [[adventitia]] and periadventitial fat can occur. This can lead to the development of sudden coronary artery [[Dissection (medical)|dissection]] in a susceptible [[patient]] with underlying [[cardiovascular disease]].<br /><ref name="urlSpontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID‐19 infection - Kumar - - Catheterization and Cardiovascular Interventions - Wiley Online Library">{{cite web |url=https://onlinelibrary.wiley.com/doi/full/10.1002/ccd.28960#ccd28960-bib-0001 |title=Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID‐19 infection - Kumar - - Catheterization and Cardiovascular Interventions - Wiley Online Library |format= |work= |accessdate=}}</ref> | ||
====Non-[[Atherosclerotic]]-[[Spontaneous Coronary Artery Dissection]] (NA-[[SCAD]]):==== | ====Non-[[Atherosclerotic]]-[[Spontaneous Coronary Artery Dissection]] (NA-[[SCAD]]):==== | ||
* It can result in extensive [[Dissection (medical)|dissection]] lengths, especially in the presence of [[arterial]] fragility from predisposing [[arteriopathies]]. | |||
* | *NA-[[SCAD]] can develop in any layer ([[Tunica intima|intima]], media, or [[adventitia]]) of the [[coronary artery]] wall. However, the initiation and the pattern of [[Dissection (medical)|dissection]] in NA-[[SCAD]] is different from the pattern observed in [[patients]] with pre-existing [[atherosclerosis]]. | ||
*NA-[[SCAD]] can develop in any layer ([[Tunica intima|intima]], media, or [[adventitia]]) of the coronary artery wall. However, the initiation and the pattern of [[Dissection (medical)|dissection]] in NA-[[SCAD]] is different from the pattern observed in [[patients]] with pre-existing [[atherosclerosis | |||
==Causes== | ==Causes== | ||
[[Common]] causes of [[covid-19]]-associated with [[ | [[Common]] causes of [[covid-19]]-associated with [[spontaneous coronary artery dissection]] include: | ||
* [[Inflammation]] | * [[Inflammation]] | ||
* [[sympathetic]] overreactivity | * [[sympathetic]] overreactivity | ||
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*To view a differential diagnosis on the other causes of chest pain, [[Chest pain differential diagnosis|click here]]. | *To view a differential diagnosis on the other causes of chest pain, [[Chest pain differential diagnosis|click here]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
* The [[prevalence]] of [[spontaneous coronary artery dissection]] in [[covid-19]] | * The exact [[prevalence]] of [[spontaneous coronary artery dissection]] in [[covid-19]] is not fully understood yet. | ||
===Age=== | ===Age=== | ||
* | * The range of age of reported cases of [[spontaneous coronary artery dissection ]] associated [[covid-19]] in literature were between 35-70 years old. | ||
===Gender=== | ===Gender=== | ||
*[[Women]] are more commonly affected with [[Spontaneous coronary artery dissection]] than [[men]]. However, six of the nine [[patients]] with [[covid-19]] associated [[spontaneous coronary artery dissection]] were [[men]]. | *[[Women]] are more commonly affected with [[Spontaneous coronary artery dissection]] than [[men]]. However, six of the nine [[patients]] (77.7%) with [[covid-19]] associated [[spontaneous coronary artery dissection]] were [[men]] and (22.3%) were [[women]], that can be due to higher incidence of [[covid-19]] in [[men]].<ref name="pmid34106068">{{cite journal |vauthors=Yapan Emren Z, Emren V, Özdemir E, Karagöz U, Nazlı C |title=Spontaneous right coronary artery dissection in a patient with COVID-19 infection: A case report and review of the literature |journal=Turk Kardiyol Dern Ars |volume=49 |issue=4 |pages=334–338 |date=June 2021 |pmid=34106068 |doi=10.5543/tkda.2021.34846 |url=}}</ref> | ||
===Race=== | ===Race=== | ||
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==Risk Factors== | ==Risk Factors== | ||
* Among nine reported cases of [[covid-19]] associated [[SCAD]] there were not any previous risk factors of [[SCAD]]. | * Among nine reported cases of [[covid-19]] associated [[SCAD]], there were not any previous risk factors of [[SCAD]].<ref name="pmid34106068">{{cite journal |vauthors=Yapan Emren Z, Emren V, Özdemir E, Karagöz U, Nazlı C |title=Spontaneous right coronary artery dissection in a patient with COVID-19 infection: A case report and review of the literature |journal=Turk Kardiyol Dern Ars |volume=49 |issue=4 |pages=334–338 |date=June 2021 |pmid=34106068 |doi=10.5543/tkda.2021.34846 |url=}}</ref> | ||
*Conventionakl risk factors of [[spontaneous coronary artery dissection]] include:<ref name="SawMancini20162">{{cite journal|last1=Saw|first1=Jacqueline|last2=Mancini|first2=G.B. John|last3=Humphries|first3=Karin H.|title=Contemporary Review on Spontaneous Coronary Artery Dissection|journal=Journal of the American College of Cardiology|volume=68|issue=3|year=2016|pages=297–312|issn=07351097|doi=10.1016/j.jacc.2016.05.034}}</ref> | *Conventionakl risk factors of [[spontaneous coronary artery dissection]] include:<ref name="SawMancini20162">{{cite journal|last1=Saw|first1=Jacqueline|last2=Mancini|first2=G.B. John|last3=Humphries|first3=Karin H.|title=Contemporary Review on Spontaneous Coronary Artery Dissection|journal=Journal of the American College of Cardiology|volume=68|issue=3|year=2016|pages=297–312|issn=07351097|doi=10.1016/j.jacc.2016.05.034}}</ref> | ||
**[[Fibromuscular dysplasia]] | **[[Fibromuscular dysplasia]] | ||
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==Screening== | ==Screening== | ||
* | * There is no established screening method for [[SCAD]] in [[covid-19]] [[patients]]. However, high clinical suspicion is needed in [[patients]] with manifestation of [[acute coronary syndrome]] in the context of [[covid-19]] [[involvement]]. | ||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
*The majority of [[covid-19]] [[patients]] with [[spontaneous coronary artery dissection]] are diagnosed with [[myocardial infarction]]. | *The majority of [[covid-19]] [[patients]] with [[spontaneous coronary artery dissection]] are diagnosed with [[myocardial infarction]]. | ||
*Early clinical features include [[STEMI]], [[NSTEMI]]. | *Early clinical features include [[STEMI]], [[NSTEMI]], or symptoms unrelated to [[ACS]]. | ||
*If left untreated, [[covid-19]] [[patients]] with [[SCAD]] may progress to develop [[hemodynamic instability]], [[ongoing]] [[ischemia]], [[malignant arrhythmia]]. | *If left untreated, [[covid-19]] [[patients]] with [[SCAD]] may progress to develop [[hemodynamic instability]], [[ongoing]] [[ischemia]], [[malignant arrhythmia]]. | ||
*[[High risk]] [[angiographic]] [[features]] of [[coronary artery]] include: | *[[High risk]] [[angiographic]] [[features]] of [[coronary artery]] include: | ||
*:Impaired coronary flow | *:Impaired [[coronary]] flow | ||
*:Multivessles proximal dissections | *:Multivessles proximal dissections | ||
*:[[Left main]] lesion | *:[[Left main]] lesion | ||
*: Ostial [[LAD]] lesion | *: Ostial [[LAD]] lesion | ||
*Prognosis is dependent on the anatomical extension of [[dissection]], and survival rate of all nine reported cases in literature | *Prognosis is dependent on the anatomical extension of [[coronary arteries]] [[dissection]], and the [[survival rate]] of all nine reported cases in literature was 100%. | ||
* Table bellow shown the clinical characteristics of [[patients]] with [[covid-19]] related [[spontaneous coronary artery dissection]]:<ref name="pmid34106068">{{cite journal |vauthors=Yapan Emren Z, Emren V, Özdemir E, Karagöz U, Nazlı C |title=Spontaneous right coronary artery dissection in a patient with COVID-19 infection: A case report and review of the literature |journal=Turk Kardiyol Dern Ars |volume=49 |issue=4 |pages=334–338 |date=June 2021 |pmid=34106068 |doi=10.5543/tkda.2021.34846 |url=}}</ref><br /> | |||
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{| style="border: 2px solid #4479BA; align="left" | {| style="border: 2px solid #4479BA; align="left" | ||
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{{clear}} | {{clear}} | ||
==Diagnosis== | |||
===History and Symptoms=== | |||
[[SCAD]] can present as [[Acute coronary syndromes|acute coronary syndrome]] and [[STEMI]]. The [[symptoms]] include:<ref name="KumarVogt2020">{{cite journal|last1=Kumar|first1=Kris|last2=Vogt|first2=Joshua C.|last3=Divanji|first3=Punag H.|last4=Cigarroa|first4=Joaquin E.|title= | |||
Spontaneous coronary artery dissection of the left anterior descending artery in a patient with | Spontaneous coronary artery dissection of the left anterior descending artery in a patient with | ||
COVID | COVID | ||
‐19 infection | ‐19 infection | ||
|journal=Catheterization and Cardiovascular Interventions|year=2020|issn=1522-1946|doi=10.1002/ccd.28960}}</ref> | |journal=Catheterization and Cardiovascular Interventions|year=2020|issn=1522-1946|doi=10.1002/ccd.28960}}</ref> | ||
* Sudden onset of retrosternal pain [[chest pain]] which remains persistent in a COVID-19 [[Seropositivity|seropositive]] [[patient]] or in a patient with recent [[cough]] and [[dyspnea]] raises suspicion of [[Spontaneous coronary artery dissection|SCAD]]. | |||
* The [[chest pain]] can radiate to the left [[arm]]. | |||
* | * It can be associated with the following symptoms:<ref name="CourandHarbaoui2020">{{cite journal|last1=Courand|first1=Pierre-Yves|last2=Harbaoui|first2=Brahim|last3=Bonnet|first3=Marc|last4=Lantelme|first4=Pierre|title=Spontaneous Coronary Artery Dissection in a Patient With COVID-19|journal=JACC: Cardiovascular Interventions|volume=13|issue=12|year=2020|pages=e107–e108|issn=19368798|doi=10.1016/j.jcin.2020.04.006}}</ref> | ||
**[[Dyspnea|Difficulty breathing]] | |||
**[[Unconsciousness|Loss of consciousness]] | |||
**[[Nausea and vomiting]] | |||
**[[Diaphoresis]] | |||
*:[[Cough]] can be the perscipitant factor in the development of [[SCAD]] in [[covid-19]] [[patients]]. (10.1097/MCA.0000000000000991) | |||
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===Laboratory Findings=== | ===Laboratory Findings=== | ||
* | * There is no specific laboratory finding associated [[SCAD]] in [[covid-19]] [[patients]]. Howere, Elevated serum [[troponin]] level was detected in some cases. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
* | Common [[ECG]] findings of [[COVID-19]] associated [[SCAD]] include: | ||
* Inverted T waves | * [[ST segment elevation]] | ||
* [[Biphasic T ]] waves | |||
* Inverted [[T waves]] | |||
===X-ray=== | ===X-ray=== | ||
*There are no x-ray findings associated with COVID-19-associated spontaneous coronary artery dissection. | *There are no x-ray findings associated with COVID-19-associated spontaneous coronary artery dissection. | ||
* To view the x-ray finidings on COVID-19, [[COVID-19 x ray|click here]].<br /> | * To view the x-ray finidings on COVID-19, [[COVID-19 x ray|click here]].<br /> | ||
===Echocardiography or Ultrasound=== | ===Echocardiography or Ultrasound=== | ||
*[[Left ventricular dysfunction]] with decreased ejection fraction is seen. | *[[Left ventricular dysfunction]] with decreased [[ejection fraction]] is seen. | ||
*[[Akinesia]] or [[hypokinesia]] is seen in the affected territory of the heart. | *[[Akinesia]] or [[hypokinesia]] is seen in the affected territory of the [[heart]]. | ||
===CT scan=== | ===CT scan=== | ||
*To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]]. | *To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]]. |
Latest revision as of 04:47, 21 October 2021
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Rinky Agnes Botleroo, M.B.B.S. Ayesha Javid, MBBS[3] Synonyms and keywords: Covid-19, cardiac manifestation, Spontaneous coronary artery dissection, SCAD, Atherosclerothic-spontaneous coronary artery dissection, A-SCAD, Non-atherosclerothic spontaneous coronary artery dissection, NA-SCAD
Overview
Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is caused by novel coronavirus disease 2019 virus (COVID‐19). Cardiac manifestations and injury were identified in up to 20–28% of patients. Spontaneous coronary artery dissection (SCAD) is one of the cardiac complication of covid-19 and can be either atherosclerotic or non-atherosclerotic resulting from attaching covid-19 to ACE receptos of vessles wall and producing intense inflammation and endothelial dysfunction, sympathetic over-reactivity that are the precursors of intimal dissection. SCAD can be manifested as STEMI or NSTEMI in patients with covid-19 in which high clinical suspicion is warranted before administration of fibrinolysis in such patients. Among nine reported cases of covid-19 associated SCAD there were not found any previous conventional risk factors of SCAD such as fibromuscular disease, steraneous physical exercise, sex hormone, or peripartum period, except one case reported after intense cough in hospitalized covid-19 patients. In reported covid-19 patients associated with SCAD, it was more common in men and all nine cases were survived with consevative therapy or percutaneous coronary intervention based upon the anatomical site of dissection.
Historical Perspective
- COVID-19 was first reported in Wuhan, Hubei Province, China in December 2019.[1]
- The World Health Organization declared the COVID-19 outbreak a pandemic on March 12, 2020.
- On June 22, 2020, the first case of COVID-19 with spontaneous coronary artery dissection was reported.[2]
Classification
- Based on origin COVID-19 associated spontaneous coronary artery dissection can be of two types:[3]
- Atherosclerotic (A-SCAD)
- Non-atherosclerotic (NA-SCAD)
Pathophysiology
- SCAD can be secondary to an atherosclerotic (A-SCAD) or non-atherosclerotic (NA-SCAD) lesion in origin.
- Lessons from the previous coronavirus and influenza epidemics suggest that these viral infections can trigger acute coronary syndrome primarily owing to a combination of a significant systemic inflammatory response plus localized vascular inflammation at the arterial plaque level.
Phathophysiology of SCAD in covid-19 patients
- The exact pathogenesis of spontaneous coronary artery dissection in covid-19 patients is not fully understood.
- It is thought that SCAD in covid-19 patients is the result of either Intense inflammation and endothelial dysfunction causing sympathetic overreactivity leading to intimal dissection.
- High dose of corticosteroid therapy may induce spontaneous rupture of injured arterial wall.
- Covid-19 may causes activation and infiltration of T cells in coronary adventitia and periadventitial fat leading to release of cytokines and protease and dissection of injured wall.
- Covid-19 may enhance angiogenesis and proliferation of vasavasarum.
- Rupture of fragiled vasavasarum is the cause of intramural hematoma.
- Transition of inflammatory cell via vasavasarum to the medial and adventitial layers of the vessels may lead to rupture of vasavasarum.
- Covid-19 may attach to ACE receptors on endothelial and smooth muscle of coronary artery leading to inflammation in the muscle wall, massive death of endotheliocytes, vascular tone impairment, hemostatic impairment, and vulnerability of vessels wall to dissection.
Atherosclerotic-Spontaneous Coronary Artery Dissection (A-SCAD) :
- Coronary artery dissection may be related to intraplaque hemorrhage resulting in an intra-adventitial hematoma, which can spread longitudinally along the coronary artery, dissecting the tunicae.[2][4]
- In COVID-19 patients, due to high inflammatory load, a localized inflammation of the coronary adventitia and periadventitial fat can occur. This can lead to the development of sudden coronary artery dissection in a susceptible patient with underlying cardiovascular disease.
[5]
Non-Atherosclerotic-Spontaneous Coronary Artery Dissection (NA-SCAD):
- It can result in extensive dissection lengths, especially in the presence of arterial fragility from predisposing arteriopathies.
- NA-SCAD can develop in any layer (intima, media, or adventitia) of the coronary artery wall. However, the initiation and the pattern of dissection in NA-SCAD is different from the pattern observed in patients with pre-existing atherosclerosis.
Causes
Common causes of covid-19-associated with spontaneous coronary artery dissection include:
- Inflammation
- sympathetic overreactivity
- Use of corticosteroids
- Underlying coronary artery disease
- For other causes of spontaneous coronary artery dissection, Click here.
Differentiating COVID-19-associated spontaneous coronary artery dissection from other Diseases
- To view the differential diagnosis of COVID-19, click here.
- To view a differential diagnosis on the other causes of chest pain, click here.
Epidemiology and Demographics
- The exact prevalence of spontaneous coronary artery dissection in covid-19 is not fully understood yet.
Age
- The range of age of reported cases of spontaneous coronary artery dissection associated covid-19 in literature were between 35-70 years old.
Gender
- Women are more commonly affected with Spontaneous coronary artery dissection than men. However, six of the nine patients (77.7%) with covid-19 associated spontaneous coronary artery dissection were men and (22.3%) were women, that can be due to higher incidence of covid-19 in men.[6]
Race
- There is no racial predilection for spontaneous coronary artery dissection associated with covid-19.
Risk Factors
- Among nine reported cases of covid-19 associated SCAD, there were not any previous risk factors of SCAD.[6]
- Conventionakl risk factors of spontaneous coronary artery dissection include:[4]
- Fibromuscular dysplasia
- Pregnancy
- Recurrent pregnancies: multiparity or multigravida
- Connective tissue disorder: Marfan syndrome, Loeys-Dietz syndrome, Ehler-Danlos syndrome type 4, cystic medial necrosis, alpha-1 antitrypsin deficiency, polycystic kidney disease
- Systemic inflammatory disease: systemic lupus erythematosus, Crohn’s disease, ulcerative colitis, polyarteritis nodosa, sarcoidosis, Churg-Strauss syndrome, Wegener’s granulomatosis, rheumatoid arthritis, Kawasaki, giant cell arteritis, celiac disease
- Hormonal therapy: oral contraceptive, estrogen, progesterone, beta-HCG, testosterone, corticosteroids
- Coronary artery spasm
- Idiopathic[4]
- Strenous exercises (isometric or aerobic activities)
- Intense emotional stress
- Labor and delivery
- Intense Valsalva-type activities (e.g., retching, vomiting, bowel movement, coughing)
- Recreational drugs (e.g., cocaine, amphetamines, metamphetamines)
- Intense hormonal therapy (e.g., beta-HCG injections, corticosteroids injections)
Screening
- There is no established screening method for SCAD in covid-19 patients. However, high clinical suspicion is needed in patients with manifestation of acute coronary syndrome in the context of covid-19 involvement.
Natural History, Complications, and Prognosis
- The majority of covid-19 patients with spontaneous coronary artery dissection are diagnosed with myocardial infarction.
- Early clinical features include STEMI, NSTEMI, or symptoms unrelated to ACS.
- If left untreated, covid-19 patients with SCAD may progress to develop hemodynamic instability, ongoing ischemia, malignant arrhythmia.
- High risk angiographic features of coronary artery include:
- Prognosis is dependent on the anatomical extension of coronary arteries dissection, and the survival rate of all nine reported cases in literature was 100%.
- Table bellow shown the clinical characteristics of patients with covid-19 related spontaneous coronary artery dissection:[6]
Age, sex | Cardiovascular history | Symptoms | Predisposing factors | Timing according to covid-19 infection | Concomitant covid-19 complications | Covid-19 severity | Diagnosis | Vessle | Treatment | Outcome |
---|---|---|---|---|---|---|---|---|---|---|
45 years, female | None | Anosmia, hypogeusia, chest pain | Not reported | 8 weeks | None | Mild | STEMI | LAD | Conservative, dual antiplatelet, betablocker, ACE inhibitor | Survived |
40 years, male | None | Fever, cough | Not reported | 7 days after ECMO | Cardiogenic shock, severe respiratory distress syndrome, cardiac thrombosis | Severe lung infiltration | NSTEMI | LAD | Conservative | Survived |
48 years, female[7] | Hyperlipidemia | Chest pain | Not reported | COVID-19 PCR was tested after SCAD | Polymorphic ventricular tachycardia | Mild | STEMI | LAD | Conservative, dual antiplatelet, betablocker, amiodarone | Survived |
55 years, male[2] | Peripheral arterial disease | Fever, cough, chest pain, dyspnea | Not reported | 48 hours after obtained test | None | Moderate, crazy pavy patten in lung | NSTEMI | RCA | Conservative, ASA, statin, betablocker | Survived |
70 years, male[3] | Smoker, hypertension, diabetes mellitus | Fever, chest pain | Not reported | Positive covid-19 test one day after angiography | None | Mild | NSTEMI | LAD | PCI, ASA, statin, betablocker, clopidogrel, metformine, pantoprazole | Survived |
39 years, male | None | Fever, cough, myalgia, chest pain, dyspnea | Not reported | 18 days after [[covid-19] | None | Severe, respiratory failure leading to intubation | STEMI | LAD, LCX | Conservative, dual antiplatelet | Survived |
51 years, female | Hypertension, smoker | Fever, cough, dyspnea | Not reported | 3 days | None | Mild | NSTEMI | LAD | Conservative, dual antiplatelet, anticoagulant, statin | Survived |
35 years, male | Obese, smoker | Weakness, fever, nasal congestion, anosmia, dry cough, chest congestion | Autoimmune disease were ruled out | 18 days | None | Mild | STEMI | RCA, Ramus intermedius | RCA conservative treatment, PCI of ramus intermedius, dual antiplatelet, anticoagulant, statin | Survived |
50 years, male | None | Cough, fever, chest pain (later) | None | 7 days | None | Mild | STEMI | RCA | PCI, dual antiplatelet, statin, metoral | Survived |
Diagnosis
History and Symptoms
SCAD can present as acute coronary syndrome and STEMI. The symptoms include:[7]
- Sudden onset of retrosternal pain chest pain which remains persistent in a COVID-19 seropositive patient or in a patient with recent cough and dyspnea raises suspicion of SCAD.
- The chest pain can radiate to the left arm.
- It can be associated with the following symptoms:[2]
Laboratory Findings
- There is no specific laboratory finding associated SCAD in covid-19 patients. Howere, Elevated serum troponin level was detected in some cases.
Electrocardiogram
Common ECG findings of COVID-19 associated SCAD include:
- ST segment elevation
- Biphasic T waves
- Inverted T waves
X-ray
- There are no x-ray findings associated with COVID-19-associated spontaneous coronary artery dissection.
- To view the x-ray finidings on COVID-19, click here.
Echocardiography or Ultrasound
- Left ventricular dysfunction with decreased ejection fraction is seen.
- Akinesia or hypokinesia is seen in the affected territory of the heart.
CT scan
- To view the CT scan findings on COVID-19, click here.
MRI
- To view the MRI findings on COVID-19, click here.
Other Imaging Findings
Coronary angiography
- Invasive coronary angiography is the "gold standard" used for the diagnosis of SCAD.
Other Diagnostic Studies
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT)
- These imaging modalities show detailed morphology about the intramural lesion in situations when angiographic images are not clear. IVUS is important in the followup of the treatment of SCAD patients.
- OCT is superior for visualizing intimal tears, intraluminal thrombi, false lumens, and intramural hematoma, but it is limited by optical penetration and shadowing, and may not depict the entire depth of the Intramural hematoma.OCT is preferred for imaging SCAD due to its superiority and ease in visualizing intramural hematoma , intimal disruption, and double lumens.[4]
Treatment
Medical Therapy
- Antiplatelet therapy: The role of antiplatelet therapy for SCAD is unknown, but on the basis of the totality of evidence for aspirin in ACS and secondary prevention, along with its low side effect profile, aspirin appears reasonable to use for acute and long-term SCAD management. Clopidogrel for acute management of SCAD patients not treated with stents is of uncertain benefit.[4]
- Statins: The use of statins for SCAD is controversial. The bulk of data for ACS demonstrates significant benefit with lipid lowering, and statins are routinely recommended post-MI. Because of the uncertainty and the general lack of atherosclerosis in SCAD patients, statins tend to only be administered to patients with pre-existing dyslipidemia.
- Beta-blockers: Beta-blocker is associated with decreased recurrence of SCAD.[8].There is a general agreement that beta blockers take the most important place in the medical management of SCAD patients. These agents may improve the outcomes of SCAD patients with reducing vascular wall shear stress likewise in patients with aortic dissection.Furthermore, beta blockers should be used in these group of patients in order to reduce complications of myocardial infarction.[9][10]
Percutaneous coronary artery intervention (PCI)
- Conservative management should be the first choice if emergent revascularization is not necessary.
- To read more about PCI in Spontaneous Coronary Artery Dissection, Click here.
Coronary Artery Bypass Graft (CABG)
- Coronary Artery Bypass Graft (CABG) should be considered for patients with left main dissections, extensive dissections involving proximal arteries, or in patients in whom PCI failed or who are not anatomically suitable for PCI.[4]
Primary Prevention
- Limiting transmission of the SARS-CoV2 virus while protecting patients and members of healthcare team is a prime goal and cardiac catheterization laboratory protocols must be rapidly evolved to maintain high‐quality and safe cardiovascular care amidst the current pandemic.[7]
- COVID‐19 testing prior to catheterization procedures where feasible
- Adequate PPE to protect team members in COVID‐19 unknown or pending cases to reduce the risk of unplanned aerosol producing procedures such as intubation or CPR.
Secondary Prevention
- There is no secondary measures for COVID-19-associated spontaneous coronary artery dissection.
References
- ↑ Meng X, Deng Y, Dai Z, Meng Z (June 2020). "COVID-19 and anosmia: A review based on up-to-date knowledge". Am J Otolaryngol. 41 (5): 102581. doi:10.1016/j.amjoto.2020.102581. PMC 7265845 Check
|pmc=
value (help). PMID 32563019 Check|pmid=
value (help). - ↑ 2.0 2.1 2.2 2.3 Courand, Pierre-Yves; Harbaoui, Brahim; Bonnet, Marc; Lantelme, Pierre (2020). "Spontaneous Coronary Artery Dissection in a Patient With COVID-19". JACC: Cardiovascular Interventions. 13 (12): e107–e108. doi:10.1016/j.jcin.2020.04.006. ISSN 1936-8798.
- ↑ 3.0 3.1 Seresini, Giuseppe; Albiero, Remo; Liga, Riccardo; Camm, Christian Fielder; Liga, Riccardo; Camm, Christian Fielder; Thomson, Ross (2020). "Atherosclerotic spontaneous coronary artery dissection (A-SCAD) in a patient with COVID-19: case report and possible mechanisms". European Heart Journal - Case Reports. doi:10.1093/ehjcr/ytaa133. ISSN 2514-2119.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Saw, Jacqueline; Mancini, G.B. John; Humphries, Karin H. (2016). "Contemporary Review on Spontaneous Coronary Artery Dissection". Journal of the American College of Cardiology. 68 (3): 297–312. doi:10.1016/j.jacc.2016.05.034. ISSN 0735-1097.
- ↑ "Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID‐19 infection - Kumar - - Catheterization and Cardiovascular Interventions - Wiley Online Library".
- ↑ 6.0 6.1 6.2 Yapan Emren Z, Emren V, Özdemir E, Karagöz U, Nazlı C (June 2021). "Spontaneous right coronary artery dissection in a patient with COVID-19 infection: A case report and review of the literature". Turk Kardiyol Dern Ars. 49 (4): 334–338. doi:10.5543/tkda.2021.34846. PMID 34106068 Check
|pmid=
value (help). - ↑ 7.0 7.1 7.2 Kumar, Kris; Vogt, Joshua C.; Divanji, Punag H.; Cigarroa, Joaquin E. (2020). "Spontaneous coronary artery dissection of the left anterior descending artery in a patient with
COVID
‐19 infection". Catheterization and Cardiovascular Interventions. doi:10.1002/ccd.28960. ISSN 1522-1946. line feed character in
|title=
at position 96 (help) - ↑ Saw J, Humphries K, Aymong E, Sedlak T, Prakash R, Starovoytov A; et al. (2017). "Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence". J Am Coll Cardiol. 70 (9): 1148–1158. doi:10.1016/j.jacc.2017.06.053. PMID 28838364 PMID 28838364 Check
|pmid=
value (help). - ↑ Amsterdam, Ezra A.; Wenger, Nanette K.; Brindis, Ralph G.; Casey, Donald E.; Ganiats, Theodore G.; Holmes, David R.; Jaffe, Allan S.; Jneid, Hani; Kelly, Rosemary F.; Kontos, Michael C.; Levine, Glenn N.; Liebson, Philip R.; Mukherjee, Debabrata; Peterson, Eric D.; Sabatine, Marc S.; Smalling, Richard W.; Zieman, Susan J. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary". Circulation. 130 (25): 2354–2394. doi:10.1161/CIR.0000000000000133. ISSN 0009-7322.
- ↑ "Acute Myocardial Infarction in Women | Circulation".