COVID-19-associated spontaneous coronary artery dissection: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
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*[[Spontaneous coronary artery dissection|SCAD]] can be secondary to an atherosclerotic (A-SCAD) or non-atherosclerotic (NA-SCAD) lesion. | *[[Spontaneous coronary artery dissection|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. | * 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. | ||
====SCAD | |||
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====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. <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> | *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. <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> | ||
*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="SawMancini2016">{{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="SawMancini2016">{{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 in a susceptible patient with underlying cardiovascular disease. | |||
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====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<ref name="SeresiniAlbiero20202">{{cite journal|last1=Seresini|first1=Giuseppe|last2=Albiero|first2=Remo|last3=Liga|first3=Riccardo|last4=Camm|first4=Christian Fielder|last5=Liga|first5=Riccardo|last6=Camm|first6=Christian Fielder|last7=Thomson|first7=Ross|title=Atherosclerotic spontaneous coronary artery dissection (A-SCAD) in a patient with COVID-19: case report and possible mechanisms|journal=European Heart Journal - Case Reports|year=2020|issn=2514-2119|doi=10.1093/ehjcr/ytaa133}}</ref> | |||
*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, [[Spontaneous coronary artery dissection pathophysiology|Click here]]. | |||
==Causes== | ==Causes== | ||
*COVID‐19 associated spontaneous coronary artery dissection is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2). | *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. | *For other causes of spontaneous coronary artery dissection, [[Spontaneous coronary artery dissection causes|Click here]]. | ||
==Differentiating COVID-19-associated spontaneous coronary artery dissection from other Diseases== | ==Differentiating COVID-19-associated spontaneous coronary artery dissection from other Diseases== | ||
Revision as of 05:57, 12 July 2020
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COVID-19-associated spontaneous coronary artery dissection On the Web |
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American Roentgen Ray Society Images of COVID-19-associated spontaneous coronary artery dissection |
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FDA on COVID-19-associated spontaneous coronary artery dissection |
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CDC on COVID-19-associated spontaneous coronary artery dissection |
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COVID-19-associated spontaneous coronary artery dissection in the news |
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Blogs on COVID-19-associated spontaneous coronary artery dissection |
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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
Epidemiology and Demographics
Risk Factors
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:[8]
- 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
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.[9]
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 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.
- ↑ 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.
- ↑ 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).