COVID-19-associated spontaneous coronary artery dissection

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For COVID-19 frequently asked inpatient questions, click here

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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

Pathophysiology

Phathophysiology of SCAD in covid-19 patients

Atherosclerotic-Spontaneous Coronary Artery Dissection (A-SCAD) :

Non-Atherosclerotic-Spontaneous Coronary Artery Dissection (NA-SCAD):

Causes

Common causes of covid-19-associated with spontaneous coronary artery dissection include:

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

Age

Gender


Race

Risk Factors

Screening

Natural History, Complications, and Prognosis

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[6] 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:[6]

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

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

CT scan

  • To view the CT scan findings on COVID-19, click here.

MRI

Other Imaging Findings

Coronary angiography

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.[7].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.[8][9]

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.[6]
  • 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

  1. 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. 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. 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. 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.
  5. "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. 6.0 6.1 6.2 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)
  7. 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).
  8. 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.
  9. "Acute Myocardial Infarction in Women | Circulation".