SPONTANEOUS CORONARY ARTERY DISSECTION IN A PATIENT WITH CUSHING DISEASE

Abstract

Objective: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction, caused by a non-traumatic and non-iatrogenic separation of the coronary arterial wall, especially amongst young women with no conventional cardiovascular risk factors. The most common factors associated with SCAD are fibromuscular dysplasia (FMD), postpartum, multiparity, connective tissue disorders, systemic inflammatory conditions and hormonal therapy. After extensive diagnostic workup some cases are labeled as idiopathic. In the literature reported cases of aortic, cervical and carotid arterial dissections, but not SCAD, were associated with Cushing syndrome. Design and method: We describe a 46-year-old woman with a past medical history of Cushing disease (ACTH-producing pituitary tumor) treated surgically in 2009 that presented with SCAD. Results: A nulliparous, hypertensive, obese and non-smoker 46-year-old woman with a surgically treated Cushing disease in 2009, presented to the emergency department with a retrosternal chest pain with radiation to the left arm lasting for 30 minutes, nausea and diaphoresis. No ischemic changes were seen in the electrocardiogram but serum high sensitive troponin I test rose to a pic level of, 96.3 ng/L (normal range <16 ng/L). Cardiac catheterization revealed diffuse distal stenosis of the anterior descending coronary artery, compatible with spontaneous dissection type 2, with Thrombolysis in Myocardial Infarction (TIMI) II flow. The patient was treated conservatively, with anticoagulation during hospitalization and single anti-aggregation without reported complications. Further investigations were performed to explore possible etiologies or associations for SCAD. Serum inflammatory, auto-immune and immunologic workups were negative. Angio-CT scan of the abdomen and supra-aortic trunks showed no signs of FMD or inflammatory changes. Conclusions: Cushing Syndrome is not considered a traditional risk factor for SCAD. As there are reported cases of arterial dissections in the literature associated with this entity and common causes of SCAD were excluded we hypothesized that the patient past medical history may have contributed to SCAD. In fact, high cortisol levels may increase blood vessel fragility, making vessel walls more vulnerable. To the best of our knowledge there are no other reported cases in the literature of Cushing syndrome associated SCAD.