[Acute myocardial infarction due to spontaneous coronary artery dissection]

Spontaneous coronary dissection is a rare cause of acute myocardial infarction (AMI). Its aetiology and treatment have not yet been well defined. In this report, we review the clinical presentation, the aetiology, the risk factors and the treatment of 6 cases of AMI due to spontaneous coronary dissection.

We have reviewed 1100 cases of AMI having undergone coronary angiography in our institution during the period December 1999 to January 2004. Six cases (0.5%; 5 men, mean age: 38 years) in which spontaneous coronary dissection had been retained as final aetiology were further analyzed. Four patients had no cardiovascular risk factors but, interestingly, in all 6 patients we found a clear triggering factor of the acute event: extreme physical stress (5), or psychological stress (1). Thrombolysis had been performed in 5 patients, and the coronary angiography carried out thereafter showed a dissection of the left anterior descending coronary (2 cases), of the right coronary artery (3 cases) or of the left circumflex artery (1 case). All patients had a preserved coronary flow (TIMI 3). On the basis of the angiographical findings, medical treatment (4 patients), coronary artery by-pass grafting (1 patient), or percutaneous angioplasty with stenting (1 patient) were performed. The only major cardiac adverse event observed in the early follow up was a sudden acute thrombosis of the coronary stent.

In young patients without cardiovascular risk factors and presenting with AMI subsequent to a physical or emotional stress, spontaneous coronary artery dissection should imperatively be taken into consideration as a possible diagnosis. Since intravenous thrombolysis may worsen the dissection, we recommend primary emergency coronarography as a diagnostic and (sometimes) therapeutic treatment option.