Blazak Penni L, Holland David J, Basso Thomas, Martin Josh
Cardiology Department, Sunshine Coast University Hospital, Birtinya, Qld 4575, Australia.
School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane 4072, Australia.
Eur Heart J Case Rep. 2022 Mar 25;6(4):ytac125. doi: 10.1093/ehjcr/ytac125. eCollection 2022 Apr.
Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome and is associated with fibromuscular dysplasia (FMD). The diagnosis of stress cardiomyopathy in patients with SCAD and FMD is uncommon, though an important consideration given the shared risk profile. Complications of severe left ventricular (LV) dysfunction associated with stress cardiomyopathy, such as LV thrombus, complicate the management of SCAD where anticoagulation is controversial in the context of SCAD-associated intramural haematoma.
A 65-year-old female presented with non-ST elevation myocardial infarction with a recent diagnosis of hypertension but no other traditional cardiovascular risk factors. There was, however, a family history of early cardiac death from myocardial infarction affecting her mother. Echocardiography demonstrated severe biventricular dysfunction with circumferential akinesis of the mid to apical segments. Coronary angiography demonstrated type 2A SCAD involving the first diagonal artery. Cardiac magnetic resonance imaging (MRI) confirmed a diagnosis of stress cardiomyopathy with biventricular involvement, complicated by LV apical thrombus and a focal region of myocardial infarction. Vascular imaging confirmed the presence of FMD. Guideline-directed heart failure therapy in addition to clopidogrel and rivaroxaban was prescribed. Follow-up contrast echocardiography at six-weeks confirmed resolution of LV dysfunction and resolution of the LV thrombus with no adverse events.
The dual diagnosis of SCAD and stress cardiomyopathy is uncommon. Cardiac MRI was useful for confirming the diagnosis of stress cardiomyopathy and the presence of LV thrombus, where anticoagulation may complicate the management of intramural haematoma in patients with concomitant SCAD and FMD.
自发性冠状动脉夹层（SCAD）是急性冠状动脉综合征的重要病因，与纤维肌发育不良（FMD）相关。虽然鉴于SCAD和FMD患者有共同的风险特征，应激性心肌病的诊断并不常见，但却是一个重要的考虑因素。与应激性心肌病相关的严重左心室（LV）功能障碍的并发症，如左心室血栓，使SCAD的管理复杂化，因为在SCAD相关的壁内血肿情况下，抗凝治疗存在争议。
一名65岁女性因非ST段抬高型心肌梗死就诊，近期诊断为高血压，但无其他传统心血管危险因素。然而，她有家族性心肌梗死早发心脏死亡病史，其母亲受此影响。超声心动图显示严重的双心室功能障碍，中至心尖段圆周运动减弱。冠状动脉造影显示2A型SCAD累及第一对角支动脉。心脏磁共振成像（MRI）确诊为双心室受累的应激性心肌病，并发左心室心尖血栓和局灶性心肌梗死。血管成像证实存在FMD。除氯吡格雷和利伐沙班外，还给予了指南指导的心力衰竭治疗。六周后的随访对比超声心动图证实左心室功能障碍和左心室血栓消失，无不良事件。
SCAD和应激性心肌病的双重诊断并不常见。心脏MRI有助于确诊应激性心肌病和左心室血栓的存在，在合并SCAD和FMD的患者中，抗凝治疗可能会使壁内血肿的管理复杂化。
