Spontaneous Coronary Dissection

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					                              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.
Key Points:
        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
            interventional procedure
        May occur in those w/ atherosclerotic coronary heart disease, those in the peripartum
            period, and those without identifiable risk factors
Risk Factors/Demographics:
        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