Canadian Journal of Cardiology 30 (2014) 464.e1e464.e3 www.onlinecjc.ca
Case Report
Spontaneous Coronary Artery Dissection Associated With b-HCG Injections and Fibromuscular Dysplasia Mathieu Lempereur, MD,a Jasmine Grewal, MD,b and Jacqueline Saw, MDa a
Vancouver General Hospital, Vancouver, British Columbia, Canada b
St Paul’s Hospital, Vancouver, British Columbia, Canada
ABSTRACT
RESUM E
Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome predominantly affecting younger women. SCAD is often associated with predisposing arterial abnormalities and precipitating emotional, physical, and hormonal stressors. We previously showed that fibromuscular dysplasia is strongly associated with SCAD and may be a causative factor. Hormonal changes related to pregnancy and sex hormones have also been shown to be an important cause of SCAD. We describe the first case report, to our knowledge, of SCAD associated with b-human growth hormone injections in a patient with concomitant FMD.
e de l’artère coronaire (DSAC) est une cause La dissection spontane rare du syndrome coronarien aigu touchant principalement les plus e à des anomalies jeunes femmes. La DSAC est souvent associe rielles pre disposantes et à des facteurs de stress pre cipitants de arte motionnelle, physique ou hormonale. Nous avons nature e ce demment montre que la dysplasie fibromusculaire (DFM) est pre e à la DSAC et qu’elle peut être un facteur causal. fortement associe s à la grossesse et aux hormones Les changements hormonaux lie galement re ve le s être une cause importante de sexuelles se sont e crivons à notre connaissance la première observation DSAC. Nous de e à l’injection de bêta-hGH (b-human growth horde DSAC associe mone) chez une patiente ayant une DFM concomitante.
Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS) predominantly affecting younger women. Intramural hemorrhage between the intima and media or between the media and adventitia is the hallmark finding. SCAD is often associated with an underlying predisposing condition, with or without a precipitating factor. We recently discovered that fibromuscular dysplasia (FMD) is strongly associated with SCAD in the majority of patients.1 Acute hormonal changes as a precipitating factor has also been described. We report a case of SCAD associated with the use of b-human chorionic gonadotropin (HCG) injections in a patient with concomitant FMD.
(normal < 0.05 mg/L). She received tenecteplase in a remote community hospital without catheterization capacity, which intensified her chest pain initially; the pain gradually abated the next morning, with ST segment resolution overnight. She was transferred to a tertiary hospital and underwent coronary angiography 2 days later, which showed a type 1 angiographic SCAD (multiple radiolucent lumen)2 involving the mid left anterior descending (LAD) artery with complete occlusion distally (Fig. 1A). She had apical akinesis and her left ventricular ejection fraction was reduced to 45%. Given the extent of the dissection and resolution of chest pain, she was treated conservatively. A control coronary angiogram 8 weeks later showed angiographic healing of the LAD artery (Fig. 1B). Nonselective renal and iliac angiograms (Fig. 2) showed mild irregularities in the left renal artery, with dissection and occlusion of the distal inferior segment branch, and mild irregularities of both external iliac arteries consistent with FMD.
Case Presentation An obese 51-year-old women started an aggressive weightloss regimen (500 calories/d) with daily intramuscular injections of 150 units of b-HCG for 23 days. Two weeks after completion of this regimen, she presented to the emergency department with severe bilateral shoulder pain, dynamic anterior ST elevation, and elevated troponin T levels of 29 mg/L Received for publication November 14, 2013. Accepted November 29, 2013. Corresponding author: Dr Jacqueline Saw, Vancouver General Hospital, 2775 Laurel St, Level 9, Vancouver, British Columbia V5Z 1M9, Canada. Tel.: þ1-604-875-5547. E-mail: [email protected] See page 464.e3 for disclosure information.
Discussion SCAD is a relatively infrequent cause of ACS and remains under-diagnosed. Predisposing conditions of SCAD have been broadly divided into atherosclerotic and nonatherosclerotic forms.3 Nonatherosclerotic conditions include the peripartum state, multiparous pregnancy, FMD, connective tissue disorders, systemic inflammatory conditions, and coronary artery spasm. Precipitating factors such as emotional and physical
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.11.030
464.e2
Canadian Journal of Cardiology Volume 30 2014
Figure 1. (A) Mid left anterior descending (LAD) artery dissection (arrow) extending to the apex with complete occlusion of the distal segments on the first angiogram. (B) Angiogram 8 weeks later showing healed LAD dissection with normal distal coronary flow.
stressors,1 changes in hormonal status, and hemodynamic factors are also frequently described with SCAD.3 Sex hormones appear to have pathogenic roles both as predisposing and precipitating stressors. In the setting of pregnancy, sex hormoneerelated changes in vascular architectured with impaired collagen synthesis, smooth muscle cell proliferation, and alteration of media contentdcan occur. This, compounded with the hemodynamic stresses of pregnancy, can increase susceptibility to SCAD.3 Oral contraceptives have also been associated with SCAD, and there have been reports of myocardial infarction unrelated to SCAD with HCG administration for ovarian stimulation.4 To our knowledge,
our report is the first SCAD case associated with the use of HCG, which is a sex hormone produced mainly by trophoblasts and is commonly used as a pharmacologic agent to induce ovulation in women with ovulatory disorders and hypogonadotropic hypogonadism. Although the use of HCG to induce weight loss is not recommended, there seems to be a resurgence of this therapy.5 Unfortunately, the intense hormonal effects from the b-HCG injections in our patient evidently induced structural alterations in the coronary arterial wall, which triggered SCAD. In our patient, the hormone-related structural arterial alterations occurred in the setting of FMD. Whether she had
Figure 2. (A) Digital subtraction angiogram of left renal artery showing minimal irregularities in the mid to distal main renal artery, and dissection of the distal inferior segmental branch (asterisk), which is occluded more distally (arrow) consistent with FMD. (B) Right and (C) left iliofemoral digital subtraction angiogram showing bilateral mild external iliac artery irregularities consistent with FMD (arrows).
Lempereur et al. SCAD and b-HCG in Fibromuscular Dysplasia
concomitant coronary FMD that compounded the b-HCG hormonal alterations further physiologically weakening the intimal-medial segment is speculative. The temporal relation of the SCAD event to the b-HCG injections implicates the latter as the key causative factor. Our case highlights an important cardiac complication associated with the use of b-HCG injections, and patients should be warned about this potential side effect. Disclosures The authors have no conflicts of interest to disclose. References 1. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous coronary artery dissection: prevalence of predisposing conditions including
464.e3 fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013;6:44-52. 2. Saw J. Coronary angiogram classification of spontaneous coronary artery dissection [epub ahead of print]. Catheter Cardiovasc Interv http://dx.doi. org/10.1002/ccd.25293, accessed December 20, 2013. 3. Saw J. Spontaneous coronary artery dissection. Can J Cardiol 2013;29: 1027-33. 4. Ludwig M, Tolg R, Richardt G, Katus HA, Diedrich K. Myocardial infarction associated with ovarian hyperstimulation syndrome. JAMA 1999;282:632-3. 5. Lovejoy JC, Sasagawa M. An unfortunate resurgence of human chorionic gonadotropin use for weight loss. Int J Obes (Lond) 2012;36:385-6.
Case Report
Spontaneous Coronary Artery Dissection Associated With b-HCG Injections and Fibromuscular Dysplasia Mathieu Lempereur, MD,a Jasmine Grewal, MD,b and Jacqueline Saw, MDa a
Vancouver General Hospital, Vancouver, British Columbia, Canada b
St Paul’s Hospital, Vancouver, British Columbia, Canada
ABSTRACT
RESUM E
Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome predominantly affecting younger women. SCAD is often associated with predisposing arterial abnormalities and precipitating emotional, physical, and hormonal stressors. We previously showed that fibromuscular dysplasia is strongly associated with SCAD and may be a causative factor. Hormonal changes related to pregnancy and sex hormones have also been shown to be an important cause of SCAD. We describe the first case report, to our knowledge, of SCAD associated with b-human growth hormone injections in a patient with concomitant FMD.
e de l’artère coronaire (DSAC) est une cause La dissection spontane rare du syndrome coronarien aigu touchant principalement les plus e à des anomalies jeunes femmes. La DSAC est souvent associe rielles pre disposantes et à des facteurs de stress pre cipitants de arte motionnelle, physique ou hormonale. Nous avons nature e ce demment montre que la dysplasie fibromusculaire (DFM) est pre e à la DSAC et qu’elle peut être un facteur causal. fortement associe s à la grossesse et aux hormones Les changements hormonaux lie galement re ve le s être une cause importante de sexuelles se sont e crivons à notre connaissance la première observation DSAC. Nous de e à l’injection de bêta-hGH (b-human growth horde DSAC associe mone) chez une patiente ayant une DFM concomitante.
Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS) predominantly affecting younger women. Intramural hemorrhage between the intima and media or between the media and adventitia is the hallmark finding. SCAD is often associated with an underlying predisposing condition, with or without a precipitating factor. We recently discovered that fibromuscular dysplasia (FMD) is strongly associated with SCAD in the majority of patients.1 Acute hormonal changes as a precipitating factor has also been described. We report a case of SCAD associated with the use of b-human chorionic gonadotropin (HCG) injections in a patient with concomitant FMD.
(normal < 0.05 mg/L). She received tenecteplase in a remote community hospital without catheterization capacity, which intensified her chest pain initially; the pain gradually abated the next morning, with ST segment resolution overnight. She was transferred to a tertiary hospital and underwent coronary angiography 2 days later, which showed a type 1 angiographic SCAD (multiple radiolucent lumen)2 involving the mid left anterior descending (LAD) artery with complete occlusion distally (Fig. 1A). She had apical akinesis and her left ventricular ejection fraction was reduced to 45%. Given the extent of the dissection and resolution of chest pain, she was treated conservatively. A control coronary angiogram 8 weeks later showed angiographic healing of the LAD artery (Fig. 1B). Nonselective renal and iliac angiograms (Fig. 2) showed mild irregularities in the left renal artery, with dissection and occlusion of the distal inferior segment branch, and mild irregularities of both external iliac arteries consistent with FMD.
Case Presentation An obese 51-year-old women started an aggressive weightloss regimen (500 calories/d) with daily intramuscular injections of 150 units of b-HCG for 23 days. Two weeks after completion of this regimen, she presented to the emergency department with severe bilateral shoulder pain, dynamic anterior ST elevation, and elevated troponin T levels of 29 mg/L Received for publication November 14, 2013. Accepted November 29, 2013. Corresponding author: Dr Jacqueline Saw, Vancouver General Hospital, 2775 Laurel St, Level 9, Vancouver, British Columbia V5Z 1M9, Canada. Tel.: þ1-604-875-5547. E-mail: [email protected] See page 464.e3 for disclosure information.
Discussion SCAD is a relatively infrequent cause of ACS and remains under-diagnosed. Predisposing conditions of SCAD have been broadly divided into atherosclerotic and nonatherosclerotic forms.3 Nonatherosclerotic conditions include the peripartum state, multiparous pregnancy, FMD, connective tissue disorders, systemic inflammatory conditions, and coronary artery spasm. Precipitating factors such as emotional and physical
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.11.030
464.e2
Canadian Journal of Cardiology Volume 30 2014
Figure 1. (A) Mid left anterior descending (LAD) artery dissection (arrow) extending to the apex with complete occlusion of the distal segments on the first angiogram. (B) Angiogram 8 weeks later showing healed LAD dissection with normal distal coronary flow.
stressors,1 changes in hormonal status, and hemodynamic factors are also frequently described with SCAD.3 Sex hormones appear to have pathogenic roles both as predisposing and precipitating stressors. In the setting of pregnancy, sex hormoneerelated changes in vascular architectured with impaired collagen synthesis, smooth muscle cell proliferation, and alteration of media contentdcan occur. This, compounded with the hemodynamic stresses of pregnancy, can increase susceptibility to SCAD.3 Oral contraceptives have also been associated with SCAD, and there have been reports of myocardial infarction unrelated to SCAD with HCG administration for ovarian stimulation.4 To our knowledge,
our report is the first SCAD case associated with the use of HCG, which is a sex hormone produced mainly by trophoblasts and is commonly used as a pharmacologic agent to induce ovulation in women with ovulatory disorders and hypogonadotropic hypogonadism. Although the use of HCG to induce weight loss is not recommended, there seems to be a resurgence of this therapy.5 Unfortunately, the intense hormonal effects from the b-HCG injections in our patient evidently induced structural alterations in the coronary arterial wall, which triggered SCAD. In our patient, the hormone-related structural arterial alterations occurred in the setting of FMD. Whether she had
Figure 2. (A) Digital subtraction angiogram of left renal artery showing minimal irregularities in the mid to distal main renal artery, and dissection of the distal inferior segmental branch (asterisk), which is occluded more distally (arrow) consistent with FMD. (B) Right and (C) left iliofemoral digital subtraction angiogram showing bilateral mild external iliac artery irregularities consistent with FMD (arrows).
Lempereur et al. SCAD and b-HCG in Fibromuscular Dysplasia
concomitant coronary FMD that compounded the b-HCG hormonal alterations further physiologically weakening the intimal-medial segment is speculative. The temporal relation of the SCAD event to the b-HCG injections implicates the latter as the key causative factor. Our case highlights an important cardiac complication associated with the use of b-HCG injections, and patients should be warned about this potential side effect. Disclosures The authors have no conflicts of interest to disclose. References 1. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous coronary artery dissection: prevalence of predisposing conditions including
464.e3 fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013;6:44-52. 2. Saw J. Coronary angiogram classification of spontaneous coronary artery dissection [epub ahead of print]. Catheter Cardiovasc Interv http://dx.doi. org/10.1002/ccd.25293, accessed December 20, 2013. 3. Saw J. Spontaneous coronary artery dissection. Can J Cardiol 2013;29: 1027-33. 4. Ludwig M, Tolg R, Richardt G, Katus HA, Diedrich K. Myocardial infarction associated with ovarian hyperstimulation syndrome. JAMA 1999;282:632-3. 5. Lovejoy JC, Sasagawa M. An unfortunate resurgence of human chorionic gonadotropin use for weight loss. Int J Obes (Lond) 2012;36:385-6.
