Coronary artery dissection
Background
Illustration showing coronary artery dissection with formation of a hematoma (purple) within the walls of the coronary artery.
- Spontaneous tear in the intimal wall of a coronary artery leading to a false lumen and intramural hematoma, similar to aortic dissection
- Much more common in young women
- Usually presents as an Anterior MI with ST changes in anterior Precordial leads (V1-V3)
Causes
- Hormonal changes in vessel wall (eg pregnancy, contraceptives)
- Shear forces
- Fibromuscular dysplasia
- Underling connective tissue disorder
- Iatrogenic (during coronary angiography)
Clinical Features
- Chest or shoulder pain
- Syncope
- Dyspnea
- Diaphoresis
- Nausea
Differential Diagnosis
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Pneumomediastinum
- Pneumothorax
- Pulmonary embolism
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Cocaine chest pain
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Drugs of abuse (eg, cocaine, crack, meth)
- Medications
Evaluation
- EKG
- Labs
- Troponin may be elevated
- Echocardiography
- Cardiology consultation
- Diagnosis made at time of coronary angiography
Management
- Aspirin, β-blocker, and 1 year of clopidogrel[1]
- PCI can be challenging given vessel wall fragility
Disposition
- Admit
See Also
- Chest Pain
- STEMI
References
- Saw J, Aymong E, Sedlak T, et al. Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes. Circ Cardiovasc Interv 2014; 7:645.
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