SPONTANEOUS CORONARY-ARTERY DISSECTION

Spontaneous coronary artery dissection is a rarely identified entity w hose exact incidence, etiology, pathogenesis, medium-term evolution, a nd optimal treatment have not yet been firmly established. This articl e describes five new cases with additional specific characteristics. F ive of 2,241 coronary arteriograms taken between September 1989 and No vember 1992 showed angiographic signs of coronary dissection. Three of the patients were treated pharmacologically, and two were operated on . All were evaluated angiographically 10-18 months after diagnosis and followed up clinically for greater-than-or-equal-to 20 months. Three patients exhibited acute myocardial infarction, one showed effort angi na and the fifth unstable angina. In four cases, coronary dissection w as associated with coronary atherosclerosis, but in the fifth the coro nary tree was apparently healthy except for the dissection. Dissection affected the right coronary artery in three cases and the left in two . Angiographic evolution varied among the five and was uncorrelated wi th treatment. Dissection disappeared in three; it persisted, with tota l obstruction of the artery in the middle of the dissected segment in one case; and advanced to affect the whole left coronary tree in the f ifth. After an 18-month follow-up, none of the five patients experienc ed symptoms. These cases provide a good illustration of the variabilit y of spontaneous coronary dissection as regards etiology, clinical pre sentation, treatment, and evolution. Coronary dissection is always cau sed by hemorrhage in the media of the arterial wall; its variability i n evolution and in optimal treatment may be derived from the cause of the hemorrage, which possibly was not the same in all cases. (C) 1994 Wiley-Liss, Inc.