Cardiovascular Disease: Student/Resident Case Report Poster - Cardiovascular Disease I |

Hyperandrogenism and Spontaneous Coronary Artery Dissection: A New Entity? FREE TO VIEW

Bronwyn Small, MD; Giordano Mitchell, MD; Daniel Hrabec, MD; Ranya Selim, MD; Dee Dee Wang, MD
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Henry Ford Hospital, Detroit, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):89A. doi:10.1016/j.chest.2016.08.097
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SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Spontaneous Coronary Artery Dissection (SCAD) is a rare clinical condition where the vascular layers of a coronary artery separate and disrupt blood flow. It commonly occurs in women without risk factors for coronary artery disease (CAD), and presents as isolated chest pain to ST-elevation myocardial infarction and sudden death. SCAD has been associated with exercise, conditions of estrogen excess (peri/postpartum, hormone prescription use), connective tissue disorders and vasculitis. CAD has been associated with elevated testosterone levels in females, however, no clear association with SCAD.

CASE PRESENTATION: A 38-year-old female with a history of polycystic ovarian syndrome (PCOS), diabetes mellitus, hypertension and hypothyroidism was admitted to hospital for chest pain. Her medical records demonstrated evidence of PCOS and hyperandrogenism; a pelvic ultrasound with multiple ovarian cysts and low serum sex-hormone binding globulin and elevated free and total testosterone levels. Her chest pain began at rest, on the left side of her chest, non-radiating. On examination, she was noted be morbidly obese, with the presence of facial hair, acanthosis nigricans, and chest hair. EKG showed a normal sinus rhythm with prolonged QT (492ms) and labs showed elevated Troponin peaking at 12.16mcg/dL. She was treated with aspirin, intravenous heparin, clopidogrel and nitroglycerin with resolution of her chest pain. She underwent left heart catheterization with evidence of single-vessel CAD (second obtuse marginal and first left postero-lateral) and SCAD of the second obtuse marginal artery. Since she had no further symptoms and no further ST-segment changes, she was medically managed, and directed to follow-up with endocrinology for hyperandrogenism.

DISCUSSION: SCAD has been documented with estrogen excess. Contributing factors include vascular endothelial change and increased shear stress. Change in vascular elastic fiber arrangement and mucopolysaccharide content occurs, and increased shear stress is expected by hormonally-mediated increases in circulating blood volumes. A similar process may occur with androgen excess leading to hemodynamic and vascular changes in this patient, culminating with SCAD and premature CAD.

CONCLUSIONS: Androgen excess can lead to pleiotropic effects in the body, including changes in the coronary arteries, leading to SCAD and CAD. We advise vigilance in evaluating patients who may be at risk with acute onset of chest pain, especially those with hormonal disturbances. For future research, it could be considered whether risk factor modification or treatment of any underlying hormonal imbalance should be addressed for patients with hormonally-driven SCAD.

Reference #1: Tweet, MS et al. Clinical features, management and prognosis of spontaneous coronary artery dissection. Circulation. 2012 Jul 31;126(5):579-88. doi: 10.1161/CIRCULATIONAHA.112.105718. Epub 2012 Jul 16.

DISCLOSURE: The following authors have nothing to disclose: Bronwyn Small, Giordano Mitchell, Daniel Hrabec, Ranya Selim, Dee Dee Wang

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