COVID-19-associated spontaneous coronary artery dissection

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Main article: COVID-19

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: 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. .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.
• 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.

Classification

• Based on origin COVID-19 associated spontaneous coronary artery dissection can be of two types:
  • 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.

SCAD due to atherosclerotic lesion

• 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.

• 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.

SCAD due to non atherosclerotic 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.

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.

Diagnosis

History and Symptoms

SCAD can present as acute coronary syndrome and NSTEMI. The 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 the following symptoms:

• Difficulty breathing
• Loss of consciousness
• Nausea and vomiting

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.

Treatment

Medical management

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