Rekürren Spontan Koroner Arter Diseksiyonu: Bir Vaka Sunumu
Özet
Spontan koroner arter diseksiyonu (SCAD), özellikle genç ve orta yaş kadınlarda görülen, aterosklerotik olmayan ve akut koroner sendromun önemli nedenlerinden biri olan bir koroner arter hastalığıdır. Tanı yöntemlerindeki gelişmelere rağmen SCAD’nin patofizyolojisi, risk faktörleri ve uzun dönem yönetimi konusunda birçok belirsizlik devam etmektedir. Rekürren spontan koroner arter diseksiyonu (R-SCAD), hastalığın prognozunu etkileyen önemli klinik sorunlardan biridir. Bu bölümde, emosyonel stres sonrası gelişen göğüs ağrısı ile başvuran, non-ST elevasyonlu miyokard enfarktüsü tanısı alan ve koroner anjiyografide sol ön inen arterde SCAD saptanan 42 yaşındaki kadın hasta sunulmuştur. Hastanın üç yıl önce farklı bir koroner arter segmentini etkileyen SCAD öyküsünün bulunması nedeniyle R-SCAD tanısı düşünülmüştür. Etiyolojik araştırmalarda romatolojik veya vasküler ek bir hastalık saptanmamış, hasta konservatif medikal tedavi ile izlenmiştir. Bir ay sonraki kontrolde diseksiyon hattında iyileşme ve sol ventrikül fonksiyonlarında düzelme gözlenmiştir. Ayrıca R-SCAD’nin epidemiyolojisi, patofizyolojisi, tanısal yaklaşımları ve güncel tedavi stratejileri gözden geçirilmiş; fibromüsküler displazi, koroner tortüozite, migren, hipertansiyon, hormonal faktörler, genetik yatkınlık ve emosyonel stres gibi rekürrensle ilişkili faktörler tartışılmıştır. Sonuç olarak, tekrarlayan akut koroner sendrom bulguları ile başvuran SCAD öykülü hastalarda R-SCAD olasılığı mutlaka değerlendirilmelidir.
Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic coronary artery disease and an important cause of acute coronary syndrome, particularly in young and middle-aged women. Despite advances in diagnostic techniques, significant uncertainties remain regarding its pathophysiology, risk factors, and long-term management. Recurrent spontaneous coronary artery dissection (R-SCAD) is a major clinical concern that may adversely affect long-term prognosis. In this chapter, we present the case of a 42-year-old woman who was admitted with chest pain following emotional stress, diagnosed with non-ST-segment elevation myocardial infarction, and found to have SCAD involving the left anterior descending artery on coronary angiography. Given her history of SCAD affecting a different coronary artery segment three years earlier, a diagnosis of R-SCAD was considered. Extensive rheumatologic and vascular evaluations revealed no associated systemic disease. The patient remained clinically stable and was managed conservatively. Follow-up coronary angiography performed one month later demonstrated healing of the dissection and improvement in left ventricular function. In addition, the epidemiology, pathophysiology, diagnostic approaches, and current treatment strategies of R-SCAD are reviewed. Factors associated with recurrence, including fibromuscular dysplasia, coronary tortuosity, migraine, hypertension, hormonal influences, genetic predisposition, and emotional stress, are discussed. In conclusion, R-SCAD should be considered in patients with a history of SCAD who present with recurrent acute coronary syndrome symptoms.
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