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: Rinky Agnes Botleroo, M.B.B.S. Ayesha Javid, MBBS[2]
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.[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
- Based on origin COVID-19 associated spontaneous coronary artery dissection can be of two types:[3]
- 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 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. [4]
- 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.[2][5]
- 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.
- 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 the most probable reason, 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
- To view the differential diagnosis of COVID-19, click here.
- To view a differential diagnosis on the other causes of chest pain, click here.
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:[5]
- 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:[5]
- Strenous exercises (isometric or aerobic activities)
- Intense emotional stress
- Labor and delivery
- Intense Valsalva-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
- Evaluation of patients presenting to the inpatient and outpatient settings during this global pandemic with cardiac chief complaints require a thorough history and examination to evaluate for potential infection with SARS‐CoV‐2.
- The virus should be on the differential for all clinicians as a possible cause of cardiopulmonary complaints. Understanding the range of cardiac manifestations and how they can affect patients can help clinicians to further care for patients with potential COVID‐19 infection.
Natural History, Complications, and Prognosis
Prognosis
- 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. Patients with prior cardiovascular injury have a fourfold increased risk of mortality compared to those without cardiovascular disease.[6][7]
Diagnosis
History and Symptoms
SCAD can present as acute coronary syndrome and NSTEMI. The symptoms include:[6]
- 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:[2]
- Below is a table presenting symptoms of the reported cases:
| Patient | Symptoms | Past medical history and risk factors | Laboratory/Imagings findings | Treatment |
|---|---|---|---|---|
| 55 years old, male admitted due
to
|
Developed chest pain 48 hrs after coming to the hospital | Peripheral artery disease[2] |
|
|
| 70-year-old, male[3] | Severe, persistent chest pain ( 8/10), which started 3 hrs before admission |
|
|
|
| 48‐year‐old, female [6]
|
Severe retrosternal chest pain,9/10, pain radiates to the neck, and both arms. |
|
|
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.
Electrocardiogram
- New ST-T abnormalities in the precordial leads which are not present earlier.
- Inverted T waves in the inferior leads.
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
- Left ventricular dysfunction with decreased ejection fraction is seen.
- Akinesia or hypokinesia is seen in the affected territory of the heart.
CT scan
- To view the CT scan findings on COVID-19, click here.
MRI
- To view the MRI findings on COVID-19, click here.
Other Imaging Findings
Coronary angiography
- Invasive coronary angiography is the "gold standard" used for the diagnosis of SCAD.
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.[5]
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.[5]
- 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.[9].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.[10][11]
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.[5]
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
- ↑ 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). - ↑ 2.0 2.1 2.2 2.3 2.4 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.
- ↑ 3.0 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.
- ↑ "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".
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 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.
- ↑ 6.0 6.1 6.2 6.3 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) - ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu Z (March 2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check
|pmc=value (help). PMID 32219356 Check|pmid=value (help). - ↑ 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 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). - ↑ 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.
- ↑ "Acute Myocardial Infarction in Women | Circulation".