Spontaneous Coronary Artery Dissection in Patients With a Provisional Diagnosis of Takotsubo Syndrome

Abstract

Background Takotsubo syndrome (TTS) mimics acute myocardial infarction in the absence of culprit coronary artery disease and is more common in women. Spontaneous coronary artery dissection (SCAD) shares a predilection for women, can result in left ventricular wall motion abnormalities similar to TTS, and may manifest subtle angiographic findings. The aim of this study was to determine the frequency of SCAD misdiagnosed as TTS. Methods and Results Coronary angiograms of patients presenting with a provisional diagnosis of TTS were retrospectively reviewed by an independent expert blinded to left ventriculography and the specific purpose of the study to assess for SCAD. TTS was defined using European Society for Cardiology criteria. SCAD was categorized according to the Saw angiographic classification. Among 80 women with a provisional diagnosis of TTS, 2 (2.5%) met angiographic criteria for definite SCAD. Both dissections were located in the distal left anterior descending coronary artery and classified as type 2b. The wall motion abnormality was apical in both cases. An additional 7 patients (9%) had angiography that was indeterminate for SCAD. Clinical characteristics of patients with and without SCAD were similar. Conclusions Among patients with a provisional diagnosis of TTS, definite SCAD in the left anterior descending coronary artery was present in 2.5% of cases, and coronary angiography was indeterminate for SCAD in an additional 9%. Careful review of coronary angiography may avoid missed diagnoses of SCAD in patients with myocardial infarction, nonobstructive coronary arteries, and wall motion abnormalities consistent with TTS. Intracoronary imaging maybe considered to establish a definitive diagnosis of SCAD when angiography is inconclusive.

Keywords: Takotsubo syndrome; coronary artery dissection; myocardial infarction.

Figure 1

Coronary angiography and left ventriculography demonstrating type 2b SCAD in 2 patients with a provisional diagnosis of TTS assigned at the time of hospital discharge. A and B, Diffuse tapering of the mid‐ and distal LAD (arrows) in patient #1 consistent with type 2b SCAD. Left ventriculography in patient #1 during diastole (C) and systole (D) demonstrates severe anterior apical, apical, and inferior apical hypokinesis with hyperdynamic basal LV segments. E and F, Diffuse narrowing of the distal LAD (arrows) in patient #2, diagnostic for type 2b SCAD. Left ventriculography during diastole (G) and systole (H) in patient #2 also revealed a severe anterior apical and apical wall motion abnormality. LAD indicates left anterior descending; SCAD, spontaneous coronary artery dissection; TTS, Takotsubo syndrome.