SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Spontaneous Coronary Artery Dissection (SCD) has 0.7-1.1% angiographic incidence and about 400 reported cases. Recurrences are rare and are usually in the index vessel.
CASE PRESENTATION: A 46-year-old Caucasian female presented with progressive sub-sternal discomfort and diaphoresis since six hours. EKG showed ST-T segment depressions in antero-lateral leads with elevated serum troponin-I of 13.8ng/mL. Prior SCD of the distal left anterior descending artery (LAD) presented as a NSTEMI two years ago, treated conservatively. After initial stabilization, urgent coronary angiogram revealed SCD of first obtuse marginal branch of the left circumflex artery with TIMI-II flow limitation. Angiographic evidence of LAD dissection, noted previously, was conspicuously absent. In the absence of occlusive dissection, patient was managed on aspirin, clopidogrel and statins. Secondary etiologies including collagen vascular disease, fibro-muscular dysplasia (FMD) and familial aneurysmal syndromes were ruled out. Subclinical hyperthyroidism (TSH 0.01mcIU/mL with normal T3/T4) with elevated thyroid peroxidase antibodies (>1000IU/mL) and thyroid-stimulating immunoglobulin (252mcU/L) was noted, but the patient refused further testing.
DISCUSSION: SCD occurs in isolation or in association with atherosclerotic coronary disease. Postulated etiopathogenic mechanisms include extramural tear and intramural hematoma. Frequent associations with hypertension, pregnancy and FMD were noted. Angiography is the gold standard of diagnosis and management is medical with selective intervention in ongoing ischemia. Spontaneous healing is considered as natural progression of the disease. Recurrence in 15-20% is associated with cessation of beta-blockers, cystic medial necrosis and hypertension. Pezzini et al. elucidated the link between Autoimmune Thyroiditis (AIT) and spontaneous cervical artery dissection. Possible interpretations include vascular damage, generalized immune activation and reverse causation. Previously, presence of plasma cells in coronary artery biopsies and association of hypothyroidism with aortic dissection has been reported. In SCD, hypothyroidism is prevelant in 6.67% cases. Hyperthyroidism, however, has not been reported in the past; but often occurs as a prelude to hypothyroidism from AIT.
CONCLUSIONS: We propose a potential association between SCD and AIT, necessitating further evaluation of etio-pathogenic mechanisms.
Reference #1: Tweet MS, Hayes SN, Pitta SR et al. Clinical features, management and prognosis of spontaneous coronary artery dissection. Circulation. 2012 Jul 31; 126(5):579-88.
Reference #2: Alfonso F, Paulo M, Lennie V et al. Spontaneous coronary artery dissection: long term follow-up of a large series of patients prospectively managed with a “conservative” therapeutic strategy. JACC Cardiovasc Interv. 2012 Oct;5(10):1062-70.
Reference #3: Pezzini A, Del Zotto E, Mazziotti G et al. Thyroid autoimmunity and spontaneous cervical artery dissection. Stroke. 2006 Sep;37(9):2375-7.
DISCLOSURE: The following authors have nothing to disclose: Saraschandra Vallabhajosyula, Manu Kaushik, Pranathi Sundaragiri, William Biddle
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