Statistics from Altmetric.com
In the excellent case report and review by Osula et al, concerning acute myocardial infarction in young adults, comment was passed on the probable mechanism of the actual myocardial infarct described, and other possible causes were reviewed.1
The point made that the diagnosis of spontaneous coronary artery dissection is often made at postmortem is accepted. However in life myocardial infarction in the young, due to spontaneous coronary artery dissection, has been linked to both immunosuppression and hypertension.2,3 There are a number of similar case series reported in the literature and it is clear from these that the survival rate is less good in the patients treated medically.4 It is also clear that thrombolytic therapy in spontaneous coronary artery dissection is potentially a “double edged sword”. Authors reporting the deterioration of patients after treatment with thrombolytics have suggested that thrombolytic induced bleeding into the dissected vessel wall is the probable cause of the clinical deterioration.5,6 Osula et al do suggest that diagnostic coronary angiography be performed in all cases but do not specify timing.
Early recognition of coronary artery angiographic abnormalities, including spontaneous dissection, is surely essential in the management of young patients with acute myocardial infarction. While recognising that the coronary arteries in this case were subsequently shown to be “normal”, it could be argued that direct coronary angiography should precede (and potentially negate the need for) thrombolytic therapy in young patients with myocardial infarction.