COVID-19-associated spontaneous coronary artery dissection: Difference between revisions
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! Symptoms | ! Symptoms | ||
! Past medical history | ! Past medical history and risk factors | ||
!Laboratory findings | !Laboratory findings | ||
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| 55 year old, male ,admitted due to cough and | | 55 year old, male ,admitted due | ||
febrile dyspnea | to cough and febrile dyspnea | ||
with suspected | |||
COVID-19. | |||
| 48 hrs after admission had chest pain | |||
| 48 hrs after admission had | |||
chest pain | |||
|Peripheral artery disease | |Peripheral artery disease | ||
| | | | ||
* <u>EKG:</u> Inverted T waves in the inferior leads | |||
* Troponin I was elevated {Hs-TnI was at 355 ng/l, then 570 ng/l | |||
3 h later (normal values <7 ng/l)} | |||
* <u>Transthoracic echocardiography:</u> Left ventricular ejection fraction | |||
60% without wall motion abnormalities, no diastolic dysfunction, | |||
and a mild mitral regurgitation | |||
* <u>Coronary angiogram</u> : Chronic total occlusion of the posterior | |||
descending artey with epicardial collateral from the left anterior descending artery. | |||
In the mid-right coronary artery, a spontaneous dissecting coronary hematoma was | |||
observed with an intimal tear | |||
* <u>Optical coherence tomography (OCT):</u> spontaneous dissecting coronary hematoma | |||
with an intimal rupture of right coronary artery | |||
| | | | ||
* Aspirin, Statins, and Beta-blockers. | |||
* Subsequent control coronary angiogram was planned. | |||
|- | |||
|- | |70-year-old, male | ||
|Severe , persistent chest pain ( 8/10), which started 3 hrs before admission | |||
| | |Smoking, Hypertension, and Type 2 diabetes, | ||
H/O percutaneous coronary intervention (PCI) with implantation of a drug-eluting stent (DES) | |||
| | | | ||
* <u>EKG</u>:new ST-T abnormalities in the precordial leads | |||
* <u>Echocardiogram:</u> Left ventricular ejection fraction 40–45% with akinesia in the LCx territory (old) and a severe hypokinesis in the left anterior ascending (LAD) territory. | |||
* <u>Coronary angiogram:</u> moderate in-stent restenosis on LCx-OM and a moderate right coronary artery (RCA) stenosis | |||
| | | | ||
* Heparin, Sublingual nitroglycerin, and Clopidogrel | |||
* Angiogram was performed | |||
|} | |} |
Revision as of 08:15, 12 July 2020
COVID-19 Microchapters |
Diagnosis |
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Treatment |
Case Studies |
COVID-19-associated spontaneous coronary artery dissection On the Web |
American Roentgen Ray Society Images of COVID-19-associated spontaneous coronary artery dissection |
FDA on COVID-19-associated spontaneous coronary artery dissection |
CDC on COVID-19-associated spontaneous coronary artery dissection |
COVID-19-associated spontaneous coronary artery dissection in the news |
Blogs on COVID-19-associated spontaneous coronary artery dissection |
Risk calculators and risk factors for COVID-19-associated spontaneous coronary artery dissection |
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: Ayesha Javid, MBBS[2] Rinky Agnes Botleroo, M.B.B.S.
Overview
Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is caused by novel coronavirus disease 2019 virus (COVID‐19).It has infected over 1.5 million patients worldwide with cardiac manifestations and injury in up to 20–28% of patients.[1] [2].Spontaneous coronary artery dissection (SCAD) is a non-iatrogenic non-traumatic separation of the coronary arterial wall. It could be either atherosclerotic or non-atherosclerotic.
Historical Perspective
- COVID-19 was first reported in Wuhan, Hubei Province,China in December 2019.[3]
- 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.[4]
Classification
- Based on origin COVID-19 associated spontaneous coronary artery dissection can be of two types:[5]
- Atherosclerotic (A-SCAD)
- Non-atherosclerotic (NA-SCAD)
Pathophysiology
- SCAD can be secondary to an atherosclerotic (A-SCAD) or non-atherosclerotic (NA-SCAD) lesion.
- 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.
Atherosclerotic-Spontaneous Coronary Artery Dissection (A-SCAD) :
- While the exact mechanism of cardiac injury in this population is unknown, the proposed etiology is thought that as a result of the infection there is changes in myocardial demand leading to an ischemic cascade and increased inflammatory markers that predispose patients to plaque instability and subsequent rupture. [1]
- 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.[4][6]
- 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.
Non-Atherosclerotic-Spontaneous Coronary Artery Dissection (NA-SCAD):
- Contemporary usage of the term ‘SCAD’ is typically synonymous with NA-SCAD. It can result in extensive dissection lengths, especially in the presence of arterial fragility from predisposing arteriopathies[7]
- 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.
- At present the pathophysiology of non-atherosclerotic spontaneous coronary artery dissection (NA-SCAD) continues to be poorly understood due to the rarity of this condition and its heterogeneous pathology. Although intimal tear or bleeding of vasa vasorum with intramedial hemorrhage seems to be most probable reasons, the exact underlying mechanism is still unknown.
To read more about the pathophysiology of Spontaneous Coronary Artery Dissection, Click here.
Causes
- COVID‐19 associated spontaneous coronary artery dissection is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2).
- For other causes of spontaneous coronary artery dissection, Click here.
Differentiating COVID-19-associated spontaneous coronary artery dissection from other Diseases[8]
Differential Diagnosis[9] | Similarities | Differences |
---|---|---|
Athersclerotic Acute Coronary Syndrome |
|
|
Takotsubo Cardiomyopathy
|
|
|
Coronary Embolism
|
|
|
Coronary Spasm
|
|
|
Epidemiology and Demographics
- Huang et al[10] reported that 12% of patients with COVID-19 were diagnosedto have acute myocardial injury. According other recent data, among 138 hospitalized patients with COVID-19, 16.7% had arrhythmias and 7.2% had acute myocardial injury
- A 70-year-old man with COVID-19 associated SCAD was reported in March 2020.[5]
- A 48-year-old woman with a past medical history of migraines and hyperlipidemia also reported having COVID-19 associated SCAD[11]
- A 55-year-old man with a medical history of peripheral artery also was diagnosed with COVID-19 associated SCAD[4]
Risk Factors
- Patients with COVID-19 infection who have underlying Cardiovascular disease are more likely to develop SCAD and more severe adverse outcomes when myocardial injury occurs after COVID-19 infection and face higher risk of death,
- There is often an associated underlying predisposing arteriopathy, which may be compounded by a precipitating stressor, culminating in the phenotypic expression of SCAD
- Predisposing Factors:[12]
- 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
- Precipitating stressors:[13]
- Strenous exercises (isometric or aerobic activities)
- Intense emotional stress
- Labor and delivery
- Intense Valsava-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
Natural History, Complications, and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
SCAD can present as acute coronary syndrome and NSTEMI. The symptoms include:[11]
- 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:[4]
- Difficulty breathing
- Loss of consciousness
- Nausea and vomiting
- Here is a table presenting symptoms of the reported cases
Patient | Symptoms | Past medical history and risk factors | Laboratory findings | Treatment |
---|---|---|---|---|
55 year old, male ,admitted due
to cough and febrile dyspnea with suspected COVID-19.
|
48 hrs after admission had
chest pain |
Peripheral artery disease |
3 h later (normal values <7 ng/l)}
60% without wall motion abnormalities, no diastolic dysfunction, and a mild mitral regurgitation
descending artey with epicardial collateral from the left anterior descending artery. In the mid-right coronary artery, a spontaneous dissecting coronary hematoma was observed with an intimal tear
with an intimal rupture of right coronary artery |
|
70-year-old, male | Severe , persistent chest pain ( 8/10), which started 3 hrs before admission | Smoking, Hypertension, and Type 2 diabetes,
H/O percutaneous coronary intervention (PCI) with implantation of a drug-eluting stent (DES) |
|
|
Physical Examination
Laboratory Findings
- Elevated serum troponin level.
- Increased high-sensitivity cardiac troponin T-test (hs-cTnT).
- Increased D-dimer.
- Blood count is usually in the normal range.
- Inflammatory markers are usually in the normal range.
ECG
- new ST-T abnormalities in the precordial leads which are not present earlier.
- inverted T waves in the inferior leads.
Coronary angiography
- Invasive coronary angiography is the "gold standard" used for the diagnosis of SCAD.
Echocardiogram
- Left ventricular dysfunction with decreased ejection fraction is seen.
- Akinesia or hypokinesia is seen in the affected territory of the heart.
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.
Optical coherence tomography (OCT)
Treatment
Medical Therapy
Medical management
- Aspirin:
- Statins:
- Beta-blockers: Beta-blocker is associated with decreased recurrence of SCAD.[14]
Percutaneous coronary artery intervention (PCI)
Surgery
Coronary Artery Bypass Graft (CABG)
References
- ↑ 1.0 1.1 "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".
- ↑ 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). - ↑ 4.0 4.1 4.2 4.3 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.
- ↑ 5.0 5.1 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.
- ↑ 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.
- ↑ 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.
- ↑ "Table 1: Differential Diagnoses of Spontaneous Coronary Artery Dissection | RadcliffeCardiology".
- ↑ "Table 1: Differential Diagnoses of Spontaneous Coronary Artery Dissection | RadcliffeCardiology".
- ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". The Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. ISSN 0140-6736.
- ↑ 11.0 11.1 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, 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.
- ↑ 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.
- ↑ 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).