COVID-19-associated spontaneous coronary artery dissection

Spontaneous Coronary Artery Dissection

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.

Pathophysiology

• SCAD could be secondary to an atherosclerotic (A-SCAD) or non-atherosclerotic (NA-SCAD) lesion.
• In COVID-19 patients due to high inflammatory load, a localized inflammation of the coronary adventitia and periadventitial fat can occur. This could lead to the development of sudden coronary artery dissection in a susceptible patient with underlying cardiovascular disease.

Signs and symptoms

SCAD can present as acute coronary syndrome and NSTEMI. The signs and symptoms include;

• 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;

• Dyspnea
• Syncope
• Nausea and vomiting.

Diagnosis

Laboratory tests

• 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 followup of the treatment of SCAD patients.

Treatment

• Medical management

• Aspirin:
• Statins:
• Beta-blockers: Beta-blocker is associated with decreased recurrence of SCAD.

• Percutaneous coronary artery intervention (PCI)
• Surgery

• Coronary Artery Bypass Graft (CABG):