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Source publication
Patient: Male, 34
Final Diagnosis: Spontaneous coronary artery dissection
Symptoms: Chest pain
Medication: —
Clinical Procedure: —
Specialty: Cardiology
Objective
Rare disease
Background
Spontaneous coronary artery dissection (SCAD) is primarily found in females. SCAD can have many precipitating factors such as exercise, trauma, pregnancy, drugs,...
Context in source publication
Context 1
... the catheterization, the patient had radiolucency in the proximal left anterior descending (LAD) artery which was identified by the angiographer and looked suspicious for SCAD (Figure 1). Intravascular ultrasound was performed which dem- onstrated the false lumen and intramural hemorrhage and pos- sible thrombus/plaque formation within it (Figure 2). As the patient had NSTEMI, percutaneous coronary revascularization was performed, and 3 drug-eluting stents placed in the vessel to cover the entire length of lesion ( Figure 3). ...
Citations
... presentation between 44 and 55 years [2,6,7]. SCAD most commonly occurs in patients with few or no traditional cardiovascular risk factors [8,9]. ...
... The second mechanism presents as compression due to hematoma and needs imaging to differentiate from atherosclerotic stenosis [7]. Both mechanisms develop a false channel in the middle layer, which causes obstruction or compression of the vessel, leading to decreased blood flow to the heart and causing myocardial ischemia [1,2]. Saw [26] proposed a classification for SCAD based on coronary angiography (Fig. 2). ...
Spontaneous coronary artery dissection (SCAD) is defined as a non-iatrogenic, non-traumatic separation of the coronary artery wall, which has gained considerable recognition as an important cause of acute coronary syndrome. Despite the emerging evidence, it is still frequently missed and requires a high index of suspicion, as failure to accurately identify SCAD promptly could prove fatal. SCAD is most prevalent among middle-aged women, although it can also be found in men and postmenopausal women. Risk factors of SCAD include exogenous hormone use, physical and emotional stressors, pregnancy, and several inflammatory and connective tissue disorders. COVID-19 also contributes to the prevalence of SCAD. SCAD is classified into four main types based on the angiographic findings - type 1, type 2, type 3, and type 4. The gold standard for diagnosis is coronary angiography; however, intracardiac imaging is useful if diagnostic doubts persist. Despite the increasing recognition of this disease, there is a paucity in the guidelines on the management of SCAD. Management may be conservative, medical, or interventional. Cardiac rehabilitation is also necessary in the management of patients with SCAD. In light of the gaps in evidence, the authors aim to provide a comprehensive review of the existing literature, outlining the pathophysiology, classification, and, most importantly, the evidence and pitfalls circulating diagnosis, acute, and long-term management of SCAD.
Background
Acute coronary syndrome (ACS) is rarely caused by coronary artery disease in young patients unless cardiovascular risk factors are present. Although non-atherosclerotic causes of ACS are rare, they need to be considered in young patients.
Case summary
We report on a 21-year-old patient referred to our institution with ACS. Electrocardiogram showed ST-segment elevation and coronary angiography revealed thrombotic occlusion of the left anterior descending artery. Reperfusion was achieved by thrombus aspiration, glycoprotein IIb/IIIa inhibitors (GPI), and drug-eluting stent (DES). The patient had no cardiovascular risk factors but reported cannabis consumption before symptom onset. Although he was put on dual antiplatelet therapy and strictly advised to avoid consumption, he continued to abuse cannabis and suffered three further ACS events within 18 months: the first 8 months later caused by thrombotic occlusion of a diagonal branch treated by GPI and DES, the second after 17 months due to thrombotic re-occlusion of the diagonal branch, and the third after 18 months by thrombotic occlusion of the circumflex artery, both events treated by GPI alone (all while still using cannabis). Since then, he stopped cannabis consumption and has been symptom-free for 8 months.
Discussion
This case highlights that cannabis-induced ACS must be considered as a cause of myocardial infarction in young adults. In contrast to ACS in the elderly population, this unusual ACS cause requires specific treatment. The risk of ACS relapse may substantial if cannabis abuse is continued. This potential hazard needs to be taken into consideration when legalization of cannabis is discussed.
