ABSTRACT
Atrial fibrillation can present with symptoms of myocardial infarction and elevated troponin, even in the absence of obstructive coronary artery disease (CAD). We sought to determine the characteristics that predict underlying obstructive CAD. Obstructive CAD was far more likely in those with troponin elevation. In those with elevated troponin, diabetes mellitus was an independent predictor of obstructive CAD.
Subject(s)
Atrial Fibrillation , Coronary Artery Disease , Diabetes Mellitus , Humans , Coronary Artery Disease/complications , Coronary Artery Disease/diagnosis , Atrial Fibrillation/diagnosis , Atrial Fibrillation/epidemiology , Troponin , Risk Factors , Retrospective Studies , Diabetes Mellitus/diagnosis , Diabetes Mellitus/epidemiology , Coronary AngiographyABSTRACT
BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. METHODS: Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. RESULTS: Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51±11 and 51±10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in SCAD and control groups, respectively, despite a much lower rate of percutaneous coronary intervention in the SCAD group. No common factors could be identified regarding particular equipment or procedural factors associated with iatrogenic dissection. CONCLUSION: The rate of iatrogenic dissection in women with SCAD during cardiac catheterisation is confirmed to be high and significantly higher than a contemporaneous age-matched group of women without SCAD. This observation likely indicates generalised coronary fragility in this disease, and emphasises the importance of the utmost care in the engagement, injection and intervention involving the coronary arteries in this disease. Development of a non-invasive coronary imaging modality or biomarker able to diagnose SCAD non-invasively would be a great advance in the care of patients with this condition, because it would avoid the need for invasive coronary angiography for diagnosis.
Subject(s)
Cardiac Catheterization/adverse effects , Coronary Vessels/injuries , Forecasting , Iatrogenic Disease/epidemiology , Risk Assessment/methods , Coronary Angiography , Coronary Vessel Anomalies , Coronary Vessels/diagnostic imaging , Female , Follow-Up Studies , Humans , Incidence , Middle Aged , Retrospective Studies , Risk Factors , Vascular Diseases/congenital , Victoria/epidemiologySubject(s)
Amino Acid Substitution/genetics , Aortic Dissection/genetics , Cell Adhesion Molecules/genetics , Coronary Aneurysm/genetics , Genetic Predisposition to Disease , Genetic Variation , Receptors, Cell Surface/genetics , Acute Coronary Syndrome/etiology , Adult , Adult Children , Female , Gene Frequency , Humans , Middle Aged , Mothers , Tight Junctions/geneticsABSTRACT
CLINICAL INTRODUCTION: A 42-year-old woman presented with anterior ST elevation myocardial infarction. Urgent coronary angiography revealed tapering then occlusion of the distal left anterior descending (LAD) coronary artery with no flow in the distal LAD (figure 1A). Balloon angioplasty with a 2.0×8 mm balloon re-established flow into the distal LAD. An angiogram of the right external iliac artery was also performed (figure 1B).heartjnl;104/19/1607/F1F1F1Figure 1Invasive angiography of the left coronary system (A) and the right external iliac artery (B). The coronary angiogram (A) shows tapering and then occlusion (arrow) of the distal left anterior descending coronary artery. QUESTION: Which of the following explains the abnormal appearance of the external iliac artery (figure 1B)?Atherosclerosis.Concertina effect.Fibromuscular dysplasia.Perforation.Multiple aneurysms.
