Spontaneous Coronary Artery Dissection in a Pre- Menopausal Woman Occurring Just prior to Menstruation

Case Report

INTRODUCTION

SCAD is a rare presentation of acute coronarysyndrome(ACS) and clinically indistinguishable fromplaque rupture. It predominantly affects young women withno traditional cardiovascular risk factors, especially duringthe post-partum and pre-menopausal period [1-3]. Theaetiology of SCAD is multifactorial and complex. Optimaltreatment strategy for SCAD is not clearely defined.

CASE REPORT

A forty-six year old lady presented with atypical chestpain, . She had no history of hypertension, diabetes, familyhistory of coronary artery disease, hyperlipaedemia orprevious chest pain. She was on steroid inhalers and did nottake oral contraceptives. She was a non smoker andoccasionally took alcohol. She did not abuse drugs and hadno personal or family history of Marfan syndrome, recentchest trauma or connective tissue disease. She had a regular28 day cycle with 5 days of menstruation. She presented twodays prior to starting her periods. Her admissionelectrocardiogram demonstrated ST elevation in inferiorleads. She was normotensive. A diagnosis of acute STelevation MI was made and she was successfullythrombolysed with reteplase and managed conservatively(aspirin, clopidogrel, low molecular weight heparin, andstatin). Coronary angiogram done ten days later revealeddissection of distal right coronary artery (Fig.1). Leftventriculography revealed mild inferior hypokinesia andgood LV function. As the patient had been completely painfree leading up to her angiogram, the decision was made totreat her conservatively, and she was discharged home onaspirin 75 mg daily, ramipril 5 mg daily and atorvastatin 10mg daily. She was not given beta-blockers due to history of

Asthma. Repeat angiogram after six months revealed atotally healed RCA (Fig. 2).

DISCUSSION

Spontaneous coronary artery dissection is a rare causeof acute coronary syndrome. It is typically described inhealthy women with no evidence of coronaryatherosclerosis [1-3]. SCAD is three times more likely tooccur in women than in men and is often seen in theperipartum period. Two case series have found 22% casesto occur during delivery and 78% in the post partum period[1]. SCAD has also been associated with cocaine use,

SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMANOCCURRING JUST PRIOR TO MENSTRUATION

Pradeepto Ghosh, Sunita Pillay, Sohail Khan and Anoop ChauhanDepartment of Cardiology, Lancashire Cardiac Centre, Blackpool, UK.

Correspondence to: Dr Pradeepto Ghosh, Department of Cardiology, Lancashire Cardiac Centre, Blackpool, UK.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction. It is known to occurin young women in the peripartum period. The exact aetiology is unknown. This report describes a 46 year oldpre-menopausal woman without cardiac risk factors presenting with acute inferior myocardial infarction andSCAD angiographically. She was noted to be at the end of her menstrual cycle. We believe that her SCADwas directly related to the phase of menstrual cycle she was in.

Key words: Spontaneous ceronary artery dissection, Myocardial infarction.

Fig.1. Coronary angiogram showing dissection in the distalright coronary artery.

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hypertensive crisis, haemodialysis, sexual intercourse,sleep deprivation, physical exercise, oral contraceptive useand connective disorders [2].

Histologically there was a large haematoma occupyingthe outer third of the vessel media, causing luminalencroachment [2]. Other histopathological changes includesmooth muscle cell proliferation and vacuolar and collagendegeneration, fibrosis and perivascular inflammatoryinfiltrate [3].

No specific etiology has been described. Two caseshave been reported where both women were found to bemenstruating at the time of SCAD [3]. During menstruationthe circulating levels of oestrogen and progesterone are attheir lowest. In premanopausal women with variant angina,frequency of ischaemic episodes was highest from the endof the luteal phase to the beginning of the menstrual phaseand was lowest in the follicular phase [4]. The suppressiveeffects of oestrogen, on vascular smooth muscle cellactivity is described [5]. Moreover oestrogen is thought tohave a direct atheroprotective effect through inhibition ofgrowth regulatory factors [5]. It has been suggested that theloss of hormonal vascular smooth muscle cell suppressionat the time of menstruation, may lead to an increase insmooth muscle activity with resultant weakness in thetunica media [3].

Unlike in the past early routine coronary angiographyhas made antemortem diagnosis of SCAD possible: theappearance of a radiolucent intimal flap or slow clearanceof contrast from the false lumen [2]. In consecutive

coronary angiography series, the incidence of SCAD hasbeen reported from 0.1% to 1.1% [2]. However, SCADmay elude diagnosis even with angiography: if an intimaltear is absent, the medial haematoma may appear as anarrowed or occluded vessel with coronary angiography.Hence, some advocate use of Intravascular Ultrasound [2].The latter will distinguish atherosclerotic stenosis fromintimal/medial haematoma [2]. CT angiography has 99%sensitivity and 96% specificity for detecting significantcoronary stenosis, though the sensitivity for detection ofcoronary artery dissection is unknown [6].

While SCAD is well recognized as a rare cause of ACS,and sudden cardiac death, its optimal treatment is notestablished [1,6]. Stable patients with limited dissectionsfrequently are candidates for medical treatment, involvingbeta blockade to reduce vascular shear forces and antiplatelet agents to reduce thrombus formation [2]. Theuneventful long-term survival of such cases treatedconservatively has been reported [1,2]. Our case wasmanaged conservatively within follow up angiography 7months later showing complete resolution of SCAD..Ongoing ischaemia refractory to medical managementshould prompt urgent revascularization [2]. Coronaryartery bypass grafting should be reserved for patients withleft main dissection, multi vessel dissection or failure ofpercutaneous interventional procedures [2].

In conclusion, we feel that in patients of this age group(pre-menopausal) presenting with symptoms suggestive ofcoronary ischaemia, a menstrual history should be obtainedand the diagnosis of SCAD should be considered. We alsobelieve, that such patients who are clinically stable andhave limited single vessel dissection, should be managedconservatively.

REFERENCES

1. Nishant Kalra, Jeff Greenblatt, Syed Ahmed. Postpartumspontaneous coronary artery dissection (SCAD)managed conservatively. Int. Journal of Cardiology 2008;129: e53-e55.

2. Jayanth Arnold, Nick West, William Gaal, et al. The role ofintravascular ultrasound in the management ofSCAD.Cardiovascular Ultrasound 2008; 6: 24.

3. Robert Slight, Ali Asgar Behranwala, OnyekweluNzewi, et al. Spontaneous coronary artery dissection: areport of two cases occurring during menstruation. TheNew Zealand Medical Journal 2003; 116: 1181.

4. H Kawano, TMotoyama, M Oghushi. Menstrual cyclevariation of myocardial ischaemia in premanopausalwomen with variant angina. Ann Intern Med. 2001;135(11):1002-1004.

5. Okubo T, Urabe M, Tsuchiya H, et al. Effect of oestrogen

Fig.2. Follow-up angiogram 6 months later shows completehealing of distal right coronary artery dissectionfollowing conservative management.

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and progesterone on gene expression of growthregulatory molecules and proto-oncogene in vascularsmooth muscle cells. Endocr J 2000; 47:205-214.

6. Catherine Schroder, Robert C. Stoler, George B.

Branning, et al. Postpartum multivessel spontaneouscoronary artery dissection confirmed by coronary CTangiography. Baylor University Medical CenterProceedings; 19(4): 334-338.

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