Spontaneous Coronary Dissection
DeMaio, SJ et al. Clinical Course and Long-Term Prognosis of Spontaneous Coronary Artery Dissection.
Am J Card iol 1989;64:471-4.
Maeder, M et al. Pregnancy-associated spontaneous coronary artery dissection: impact of medical
treatment. Z Kardio l 2005;94:829-835.
Spontaneous coronary artery dissection may occur in those with underlying coronary
atherosclerosis, in patients without risk factors (idiopathic), and during pregnancy
and in early postpartum period.
Index of suspicion must be high to make diagnosis and evaluation of coronary
anatomy should be undertaken.
Optimal management may include: medical treatment alone (BB + antiplatelet tx);
PCI with multivessel disease, proximal dissection or involvement of large areas of
viable myocardium; CABG if LM disease, multivessel disease, failure of
May occur in those w/ atherosclerotic coronary heart disease, those in the peripartum
period, and those without identifiable risk factors
Typically affects older (>70% older than 30 years) and multiparous women
Hypercholesterolemia may play role, total cholesterol increase of 50% considered
normal during pregnancy
Sudden drop in circulating sex hormones during menstruation may be involved
Poorly understood but in pregnancy may involve weakening of arterial wall due to
impaired collagen synthesis, smooth muscle cell proliferation, alterations in
mucopolysaccharide content of media
Increase cardiac output and consecutive shear stress may play role, although CO
declines after delivery, relief of caval compression may higher preload
increased stroke volume during next 48 hours after delivery
Pregnancy related alteration of coagulation system leading to prothrombotic state
thus risk of thrombosis of false lumen and compression of true lumen
Optimal management unknown
Medical treatment for those with single vessel disease, unimpaired coronary flow,
absence of ongoing symptoms (about 50% of those w/ BB, antiplatelet tx alone
accompanied by angiographically complete healing of dissections
PCI may be preferred if isolated proximal dissection in arteries supplying large areas
of viable myocardium without sufficient collaterals
CABG may be recommend if left main dissection, multivessel disease (though some
may be candidate for PCI), failure of interventional procedures
Likely good if survive immediate consequences of dissection
81% of those who survived acute event have done well in DeMaio article