Medical College of Wuhan University of Science and Technology, Wuhan, China.
Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, China.
BMC Cardiovasc Disord. 2022 Nov 8;22(1):473. doi: 10.1186/s12872-022-02922-0.
Spontaneous coronary artery dissection (SCAD) has emerged as an increasingly diagnosed cause of ST-segment elevation myocardial infarction (STEMI), which is easily missed or delayed. The effective use of coronary angiography (CAG) and advanced intracoronary imaging examinations in STEMI patients has led to increased detection of SCAD.
A 59-year-old woman with acute angina pectoris was diagnosed with STEMI detected by electrocardiography combined with measurement of myocardial enzymes. Due to the ongoing pandemic of coronavirus disease 2019 (COVID-19) in Wuhan, she was first given thrombolytic therapy after excluding contraindications according to the requirements of the current consensus statement; however, subsequently, both the symptoms of ongoing chest pain and the electrocardiographic results indicated the failure of thrombolytic therapy, so the intervention team administered rescue percutaneous coronary intervention treatment under third-grade protection. CAG confirmed total occlusion in the distal left anterior descending (LAD) artery, with thrombolysis in myocardial infarction (TIMI) 0 flow, whereas the left circumflex and right coronary arteries appeared normal, with TIMI 3 flow. Intravenous ultrasound (IVUS) was further performed to investigate the causes of occlusion, which verified the absence of atherosclerosis but detected SCAD with intramural haematoma. During the operation, the guidewire reached the distal end of the LAD artery smoothly, the balloon was dilated slightly, and the reflow of TIMI blood could be seen by repeated CAG. During the follow-up period of one and a half years, the patient complained of occasional, slight chest tightness. The repeated CAG showed that the spontaneous dissection in the LAD artery had healed well, with TIMI 3 flow. The repeated IVUS confirmed that the SCAD and intramural haematoma had been mostly resorbed and repaired.
This was a case of failed STEMI thrombolysis in our hospital during the outbreak of COVID-19. This case indicates that doctors need to consider the cause of the disease when treating STEMI patients, especially patients without traditional cardiovascular risk factors. Moreover, CAG and intracoronary imaging examinations should be actively performed to identify the aetiology and improve the treatment success rate.
自发性冠状动脉夹层（SCAD）已成为 ST 段抬高型心肌梗死（STEMI）越来越常见的诊断原因，易被漏诊或延迟诊断。在 STEMI 患者中有效应用冠状动脉造影（CAG）和先进的冠状动脉内影像学检查，导致 SCAD 的检出率增加。
一位 59 岁女性，因急性胸痛就诊，心电图结合心肌酶检测诊断为 STEMI。由于当时武汉 2019 冠状病毒病（COVID-19）大流行，根据当时共识声明的要求，在排除禁忌证后首先给予溶栓治疗；然而，随后持续胸痛的症状和心电图结果提示溶栓治疗失败，因此介入团队在三级防护下进行了挽救性经皮冠状动脉介入治疗。CAG 证实左前降支（LAD）远段完全闭塞，血流 TIMI 0 级，而左回旋支和右冠状动脉正常，血流 TIMI 3 级。进一步行静脉内超声（IVUS）检查以明确闭塞原因，结果证实无动脉粥样硬化，但检测到壁内血肿所致 SCAD。手术中，导丝顺利进入 LAD 远段，球囊轻度扩张，反复 CAG 可见 TIMI 血流再通。在 1 年半的随访期间，患者偶尔诉轻度胸闷。重复 CAG 显示 LAD 动脉自发性夹层愈合良好，血流 TIMI 3 级。重复 IVUS 证实 SCAD 和壁内血肿大部分吸收修复。
这是我院在 COVID-19 大流行期间溶栓治疗失败的 STEMI 病例。该病例提示，在治疗 STEMI 患者时，医生需要考虑病因，特别是对于无传统心血管危险因素的患者。此外，应积极进行 CAG 和冠状动脉内影像学检查，以明确病因，提高治疗成功率。
