Spontaneous coronary artery dissection causes: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Spontaneous coronary artery dissection}} | {{Spontaneous coronary artery dissection}} | ||
{{CMG}}; {{AE}}{{NRM}} {{AKK}} | {{CMG}}; {{AE}}{{Sara.Zand}} {{NRM}} {{AKK}} | ||
{{SK}} SCAD | {{SK}} SCAD | ||
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==Overview== | ==Overview== | ||
The exact etiology of spontaneous coronary artery dissection remains elusive; however, [[fibromuscular dysplasia]] and [[takotsubo cardiomyopathy]] have been considered as the potential cause of spontaneous coronary artery dissection. | The exact etiology of [[spontaneous coronary artery dissection]] remains elusive; however, [[fibromuscular dysplasia]] and [[takotsubo cardiomyopathy]] have been considered as the potential cause of [[spontaneous coronary artery dissection]]. The underlying causes associated with [[SCAD]] include [[emotional stress]], physical [[stress]] such as extreme [[valsalva maneuver]], [[retching]], [[vomiting]], [[coughing]], [[isometric exercise]], history of using stimulant [[medications]] or [[illicit drugs]], [[pregnancy]], and [[connective tissue disorders]]. | ||
==Causes== | ==Causes== | ||
Common causes associated with [[spontaneous coronary artery dissection (SCAD | Common causes associated with [[spontaneous coronary artery dissection]] ([[SCAD]]) include:<ref name="SawMancini2016">{{cite journal|last1=Saw|first1=Jacqueline|last2=Mancini|first2=G.B. John|last3=Humphries|first3=Karin H.|title=Contemporary Review on Spontaneous Coronary Artery Dissection|journal=Journal of the American College of Cardiology|volume=68|issue=3|year=2016|pages=297–312|issn=07351097|doi=10.1016/j.jacc.2016.05.034}}</ref><ref name="pmid24227590">{{cite journal| author=Saw J| title=Coronary angiogram classification of spontaneous coronary artery dissection. | journal=Catheter Cardiovasc Interv | year= 2014 | volume= 84 | issue= 7 | pages= 1115-22 | pmid=24227590 | doi=10.1002/ccd.25293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227590 }}</ref> | ||
* [[Emotional stress]] | * [[Emotional stress]] | ||
* Physical [[stress]] such as extreme [[ | * Physical [[stress]] such as extreme [[valsalva maneuver]], [[retching]], [[vomiting]], [[coughing]], [[isometric exercise]] | ||
* Using stimulant [[medications]], [[illicit drugs]] | * Using stimulant [[medications]], [[illicit drugs]] | ||
* [[Hormonal]] triggers such as [[pregnancy]] | * [[Hormonal]] triggers such as [[pregnancy]] | ||
* [[Inflammatory disorders]] such as [[systemic lupus erythematosus]], [[sarcoidosis]], [[ | * [[Inflammatory disorders]] such as [[systemic lupus erythematosus]], [[sarcoidosis]], [[Crohn's disease]], [[Ulcerative colitis]] , [[celiac disease]], [[fibromuscular dysplasia]] (FMD), [[takotsubo cardiomyopathy]] (TCM) | ||
* [[Connective tissue disorders]] such as vascular [[Ehlers–Danlos syndrome]], [[marfan’s syndrome]], [[Loeys–Dietz syndrome]], [[cystic medial necrosis]], [[systemic lupus erythematosus]], [[polyarteritis nodosa]], [[sarcoidosis]], [[churg-Strauss syndrome]], [[wegener's granulomatosis]], [[rheumatoid arthritis]], [[Temporal arteritis|giant cell arthritis]] | |||
===Fibromuscular Dysplasia=== | ===Fibromuscular Dysplasia=== | ||
FMD is a non-[[atherosclerotic]] [[vasculopathy]] characterized by thickening, [[fibrosis]], and disarray of the arterial wall that primarily affects small and medium-sized vessels. | * [[FMD]] is a non-[[atherosclerotic]] [[vasculopathy]] characterized by thickening, [[fibrosis]], and disarray of the [[arterial]] wall that primarily affects small and medium-sized [[vessels]]. | ||
* The association between [[FMD]] and [[SCAD]] has been well described,<ref name="SawPoulter2012">{{cite journal|last1=Saw|first1=J.|last2=Poulter|first2=R.|last3=Fung|first3=A.|last4=Wood|first4=D.|last5=Hamburger|first5=J.|last6=Buller|first6=C. E.|title=Spontaneous Coronary Artery Dissection in Patients With Fibromuscular Dysplasia: A Case Series|journal=Circulation: Cardiovascular Interventions|volume=5|issue=1|year=2012|pages=134–137|issn=1941-7640|doi=10.1161/CIRCINTERVENTIONS.111.966630}}</ref><ref name="SawRicci2013">{{cite journal|last1=Saw|first1=Jacqueline|last2=Ricci|first2=Donald|last3=Starovoytov|first3=Andrew|last4=Fox|first4=Rebecca|last5=Buller|first5=Christopher E.|title=Spontaneous Coronary Artery Dissection|journal=JACC: Cardiovascular Interventions|volume=6|issue=1|year=2013|pages=44–52|issn=19368798|doi=10.1016/j.jcin.2012.08.017}}</ref><ref name="ToggweilerPuck2012">{{cite journal|last1=Toggweiler|first1=S|last2=Puck|first2=M|last3=Thalhammer|first3=C|last4=Manka|first4=R|last5=Wyss|first5=M|last6=Bilecen|first6=D|last7=Corti|first7=R|last8=Amann-Vesti|first8=B|last9=Lüscher|first9=T|last10=Wyss|first10=C|title=Associated vascular lesions in patients with spontaneous coronary artery dissection|journal=Swiss Medical Weekly|year=2012|issn=1424-7860|doi=10.4414/smw.2012.13538}}</ref><ref name="SawAymong2014">{{cite journal|last1=Saw|first1=J.|last2=Aymong|first2=E.|last3=Sedlak|first3=T.|last4=Buller|first4=C. E.|last5=Starovoytov|first5=A.|last6=Ricci|first6=D.|last7=Robinson|first7=S.|last8=Vuurmans|first8=T.|last9=Gao|first9=M.|last10=Humphries|first10=K.|last11=Mancini|first11=G. B. J.|title=Spontaneous Coronary Artery Dissection: Association With Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes|journal=Circulation: Cardiovascular Interventions|volume=7|issue=5|year=2014|pages=645–655|issn=1941-7640|doi=10.1161/CIRCINTERVENTIONS.114.001760}}</ref> | |||
*The biological proof of causation has been supported by [[histopathologic]] reports.<ref name="LieBerg1987">{{cite journal|last1=Lie|first1=J.T.|last2=Berg|first2=K.K.|title=Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction|journal=Human Pathology|volume=18|issue=6|year=1987|pages=654–656|issn=00468177|doi=10.1016/S0046-8177(87)80368-4}}</ref><ref>{{cite journal |vauthors=Mather PJ, Hansen CL, Goldman B, Inniss S, Piña I, Norris R, Jeevanandam V, Bove AA |title=Postpartum multivessel coronary dissection |journal=J. Heart Lung Transplant. |volume=13 |issue=3 |pages=533–7 |year=1994 |pmid=8061031 |doi= |url=}}</ref><ref name="BrodskyRamaswamy2007">{{cite journal|last1=Brodsky|first1=Sergey V.|last2=Ramaswamy|first2=Gita|last3=Chander|first3=Praveen|last4=Braun|first4=Alex|title=Ruptured Cerebral Aneurysm and Acute Coronary Artery Dissection in the Setting of Multivascular Fibromuscular Dysplasia|journal=Angiology|volume=58|issue=6|year=2007|pages=764–767|issn=0003-3197|doi=10.1177/0003319707303645}}</ref> | |||
* The presence of [[FMD]] may weaken the [[artery]] architecture and lead to [[aneurysm|aneurysm formation]] or [[coronary dissection]].<ref name="OlinGornik2014">{{cite journal|last1=Olin|first1=J. W.|last2=Gornik|first2=H. L.|last3=Bacharach|first3=J. M.|last4=Biller|first4=J.|last5=Fine|first5=L. J.|last6=Gray|first6=B. H.|last7=Gray|first7=W. A.|last8=Gupta|first8=R.|last9=Hamburg|first9=N. M.|last10=Katzen|first10=B. T.|last11=Lookstein|first11=R. A.|last12=Lumsden|first12=A. B.|last13=Newburger|first13=J. W.|last14=Rundek|first14=T.|last15=Sperati|first15=C. J.|last16=Stanley|first16=J. C.|title=Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions: A Scientific Statement From the American Heart Association|journal=Circulation|volume=129|issue=9|year=2014|pages=1048–1078|issn=0009-7322|doi=10.1161/01.cir.0000442577.96802.8c}}</ref> | |||
===[[Takotsubo]] Cardiomyopathy ([[TCM]])=== | |||
=== | * Both [[TCM]] and [[SCAD]] affect predominantly [[women]] and may be precipitated by [[emotional stress]] or [[exercise|strenuous exercise]] associated with [[sympathetic nerve|sympathetic]] discharge. | ||
* Numerous reports have described the concurrence of [[TCM]] and [[SCAD]].<ref name="ChouSedlak2015">{{cite journal|last1=Chou|first1=Annie Y.|last2=Sedlak|first2=Tara|last3=Aymong|first3=Eve|last4=Sheth|first4=Tej|last5=Starovoytov|first5=Andrew|last6=Humphries|first6=Karin H.|last7=Mancini|first7=G.B. John|last8=Saw|first8=Jacqueline|title=Spontaneous Coronary Artery Dissection Misdiagnosed as Takotsubo Cardiomyopathy: A Case Series|journal=Canadian Journal of Cardiology|volume=31|issue=8|year=2015|pages=1073.e5–1073.e8|issn=0828282X|doi=10.1016/j.cjca.2015.03.018}}</ref><ref name="Y-HassanHenareh2013">{{cite journal|last1=Y-Hassan|first1=Shams|last2=Henareh|first2=Loghman|title=Spontaneous coronary artery dissection triggered post-ischemic myocardial stunning and takotsubo syndrome: two different names for the same condition|journal=Cardiovascular Revascularization Medicine|volume=14|issue=2|year=2013|pages=109–112|issn=15538389|doi=10.1016/j.carrev.2012.11.005}}</ref><ref name="Y-HassanThemudo2017">{{cite journal|last1=Y-Hassan|first1=Shams|last2=Themudo|first2=Raquel|last3=Maret|first3=Eva|title=Spontaneous coronary artery dissection and takotsubo syndrome: The chicken or the egg causality dilemma|journal=Catheterization and Cardiovascular Interventions|volume=89|issue=7|year=2017|pages=1215–1218|issn=15221946|doi=10.1002/ccd.26956}}</ref><ref name="Y-HassanBöhm2016">{{cite journal|last1=Y-Hassan|first1=Shams|last2=Böhm|first2=Felix|title=The causal link between spontaneous coronary artery dissection and takotsubo syndrome: A case presented with both conditions|journal=International Journal of Cardiology|volume=203|year=2016|pages=828–831|issn=01675273|doi=10.1016/j.ijcard.2015.11.047}}</ref><ref name="YaltaUcar2016">{{cite journal|last1=Yalta|first1=Kenan|last2=Ucar|first2=Fatih|last3=Yilmaztepe|first3=Mustafa|last4=Ozkalayci|first4=Flora|title=Tako-tsubo cardiomyopathy and spontaneous coronary artery dissection: A subtle association with prognostic implications?|journal=International Journal of Cardiology|volume=202|year=2016|pages=174–176|issn=01675273|doi=10.1016/j.ijcard.2015.08.152}}</ref> | |||
< | *In the setting of [[TCM]], vigorous contraction of the [[left ventricular]] base in conjunction with the adjacent [[akinetic]]/[[dyskinetic]] segments could form a prerequisite anatomic/functional substrate for the causation of [[SCAD]].<ref name="Madias2015">{{cite journal|last1=Madias|first1=John E.|title=On a Plausible Association of Spontaneous Coronary Artery Dissection and Takotsubo Syndrome|journal=Canadian Journal of Cardiology|volume=31|issue=11|year=2015|pages=1410.e1|issn=0828282X|doi=10.1016/j.cjca.2015.07.720}}</ref> | ||
* | *The [[coronary dissection]] plane may develop as a result of excessive movement of the [[epicardial]] [[vessels]] and increased [[shear stress]] on the [[vessel]] wall at the hinge point between the [[hyperdynamic]] and [[dyskinetic]]/[[akinesia|akinetic]] [[myocardium]].<ref name="Madias2017">{{cite journal|last1=Madias|first1=John E.|title=A Possible Amphidromic Relation Between Spontaneous Coronary Artery Dissection and Takotsubo Syndrome|journal=The American Journal of Cardiology|volume=120|issue=3|year=2017|pages=e69|issn=00029149|doi=10.1016/j.amjcard.2016.10.008}}</ref> | ||
* | *The [[coronary arteries]] traversing the anterior or anterolateral wall would be more vulnerable to [[dissection]] as this region marks the transition point of the [[hyperdynamic]] [[basal segment]] and the remaining [[dyskinetic]]/[[akinesia|akinetic]] [[left ventricular]] segments. | ||
*Another plausible mechanism is that elevated [[catecholamine]] concentrations in [[TCM]] may cause [[epicardial]] [[coronary]] [[vasoconstriction]] and/or [[coronary spasm|spasm]], which in turn leads to increased [[arterial]] [[shear stress]] and subsequent [[intimal]] tear or disruption of [[vasa vasorum]].<ref name="PellicciaKaski2017">{{cite journal|last1=Pelliccia|first1=Francesco|last2=Kaski|first2=Juan Carlos|last3=Crea|first3=Filippo|last4=Camici|first4=Paolo G.|title=Pathophysiology of Takotsubo Syndrome|journal=Circulation|volume=135|issue=24|year=2017|pages=2426–2441|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.116.027121}}</ref> | |||
* | * The post-[[ischemic]] [[myocardial stunning]] associated with [[SCAD]] could lead to [[TCM]],<ref name="Y-HassanHenareh2013">{{cite journal|last1=Y-Hassan|first1=Shams|last2=Henareh|first2=Loghman|title=Spontaneous coronary artery dissection triggered post-ischemic myocardial stunning and takotsubo syndrome: two different names for the same condition|journal=Cardiovascular Revascularization Medicine|volume=14|issue=2|year=2013|pages=109–112|issn=15538389|doi=10.1016/j.carrev.2012.11.005}}</ref>, thus forming the “[[TCM]] begets [[SCAD]], and [[SCAD]] begets [[TCM]]” vicious cycle. | ||
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==References== | ==References== | ||
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[[Category:Angiographic Definitions]] | [[Category:Angiographic Definitions]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Up-To-Date]] | |||
Latest revision as of 12:38, 20 April 2021
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Spontaneous Coronary Artery Dissection Microchapters |
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Differentiating Spontaneous coronary artery dissection from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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Type 1 Type 2A Type 2B Type 3 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Nate Michalak, B.A. Arzu Kalayci, M.D. [3]
Synonyms and keywords: SCAD
Overview
The exact etiology of spontaneous coronary artery dissection remains elusive; however, fibromuscular dysplasia and takotsubo cardiomyopathy have been considered as the potential cause of spontaneous coronary artery dissection. The underlying causes associated with SCAD include emotional stress, physical stress such as extreme valsalva maneuver, retching, vomiting, coughing, isometric exercise, history of using stimulant medications or illicit drugs, pregnancy, and connective tissue disorders.
Causes
Common causes associated with spontaneous coronary artery dissection (SCAD) include:[1][2]
- Emotional stress
- Physical stress such as extreme valsalva maneuver, retching, vomiting, coughing, isometric exercise
- Using stimulant medications, illicit drugs
- Hormonal triggers such as pregnancy
- Inflammatory disorders such as systemic lupus erythematosus, sarcoidosis, Crohn's disease, Ulcerative colitis , celiac disease, fibromuscular dysplasia (FMD), takotsubo cardiomyopathy (TCM)
- Connective tissue disorders such as vascular Ehlers–Danlos syndrome, marfan’s syndrome, Loeys–Dietz syndrome, cystic medial necrosis, systemic lupus erythematosus, polyarteritis nodosa, sarcoidosis, churg-Strauss syndrome, wegener's granulomatosis, rheumatoid arthritis, giant cell arthritis
Fibromuscular Dysplasia
- FMD is a non-atherosclerotic vasculopathy characterized by thickening, fibrosis, and disarray of the arterial wall that primarily affects small and medium-sized vessels.
- The association between FMD and SCAD has been well described,[3][4][5][6]
- The biological proof of causation has been supported by histopathologic reports.[7][8][9]
- The presence of FMD may weaken the artery architecture and lead to aneurysm formation or coronary dissection.[10]
Takotsubo Cardiomyopathy (TCM)
- Both TCM and SCAD affect predominantly women and may be precipitated by emotional stress or strenuous exercise associated with sympathetic discharge.
- Numerous reports have described the concurrence of TCM and SCAD.[11][12][13][14][15]
- In the setting of TCM, vigorous contraction of the left ventricular base in conjunction with the adjacent akinetic/dyskinetic segments could form a prerequisite anatomic/functional substrate for the causation of SCAD.[16]
- The coronary dissection plane may develop as a result of excessive movement of the epicardial vessels and increased shear stress on the vessel wall at the hinge point between the hyperdynamic and dyskinetic/akinetic myocardium.[17]
- The coronary arteries traversing the anterior or anterolateral wall would be more vulnerable to dissection as this region marks the transition point of the hyperdynamic basal segment and the remaining dyskinetic/akinetic left ventricular segments.
- Another plausible mechanism is that elevated catecholamine concentrations in TCM may cause epicardial coronary vasoconstriction and/or spasm, which in turn leads to increased arterial shear stress and subsequent intimal tear or disruption of vasa vasorum.[18]
- The post-ischemic myocardial stunning associated with SCAD could lead to TCM,[12], thus forming the “TCM begets SCAD, and SCAD begets TCM” vicious cycle.
References
- ↑ Saw, Jacqueline; Mancini, G.B. John; Humphries, Karin H. (2016). "Contemporary Review on Spontaneous Coronary Artery Dissection". Journal of the American College of Cardiology. 68 (3): 297–312. doi:10.1016/j.jacc.2016.05.034. ISSN 0735-1097.
- ↑ Saw J (2014). "Coronary angiogram classification of spontaneous coronary artery dissection". Catheter Cardiovasc Interv. 84 (7): 1115–22. doi:10.1002/ccd.25293. PMID 24227590.
- ↑ Saw, J.; Poulter, R.; Fung, A.; Wood, D.; Hamburger, J.; Buller, C. E. (2012). "Spontaneous Coronary Artery Dissection in Patients With Fibromuscular Dysplasia: A Case Series". Circulation: Cardiovascular Interventions. 5 (1): 134–137. doi:10.1161/CIRCINTERVENTIONS.111.966630. ISSN 1941-7640.
- ↑ Saw, Jacqueline; Ricci, Donald; Starovoytov, Andrew; Fox, Rebecca; Buller, Christopher E. (2013). "Spontaneous Coronary Artery Dissection". JACC: Cardiovascular Interventions. 6 (1): 44–52. doi:10.1016/j.jcin.2012.08.017. ISSN 1936-8798.
- ↑ Toggweiler, S; Puck, M; Thalhammer, C; Manka, R; Wyss, M; Bilecen, D; Corti, R; Amann-Vesti, B; Lüscher, T; Wyss, C (2012). "Associated vascular lesions in patients with spontaneous coronary artery dissection". Swiss Medical Weekly. doi:10.4414/smw.2012.13538. ISSN 1424-7860.
- ↑ Saw, J.; Aymong, E.; Sedlak, T.; Buller, C. E.; Starovoytov, A.; Ricci, D.; Robinson, S.; Vuurmans, T.; Gao, M.; Humphries, K.; Mancini, G. B. J. (2014). "Spontaneous Coronary Artery Dissection: Association With Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes". Circulation: Cardiovascular Interventions. 7 (5): 645–655. doi:10.1161/CIRCINTERVENTIONS.114.001760. ISSN 1941-7640.
- ↑ Lie, J.T.; Berg, K.K. (1987). "Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction". Human Pathology. 18 (6): 654–656. doi:10.1016/S0046-8177(87)80368-4. ISSN 0046-8177.
- ↑ Mather PJ, Hansen CL, Goldman B, Inniss S, Piña I, Norris R, Jeevanandam V, Bove AA (1994). "Postpartum multivessel coronary dissection". J. Heart Lung Transplant. 13 (3): 533–7. PMID 8061031.
- ↑ Brodsky, Sergey V.; Ramaswamy, Gita; Chander, Praveen; Braun, Alex (2007). "Ruptured Cerebral Aneurysm and Acute Coronary Artery Dissection in the Setting of Multivascular Fibromuscular Dysplasia". Angiology. 58 (6): 764–767. doi:10.1177/0003319707303645. ISSN 0003-3197.
- ↑ Olin, J. W.; Gornik, H. L.; Bacharach, J. M.; Biller, J.; Fine, L. J.; Gray, B. H.; Gray, W. A.; Gupta, R.; Hamburg, N. M.; Katzen, B. T.; Lookstein, R. A.; Lumsden, A. B.; Newburger, J. W.; Rundek, T.; Sperati, C. J.; Stanley, J. C. (2014). "Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions: A Scientific Statement From the American Heart Association". Circulation. 129 (9): 1048–1078. doi:10.1161/01.cir.0000442577.96802.8c. ISSN 0009-7322.
- ↑ Chou, Annie Y.; Sedlak, Tara; Aymong, Eve; Sheth, Tej; Starovoytov, Andrew; Humphries, Karin H.; Mancini, G.B. John; Saw, Jacqueline (2015). "Spontaneous Coronary Artery Dissection Misdiagnosed as Takotsubo Cardiomyopathy: A Case Series". Canadian Journal of Cardiology. 31 (8): 1073.e5–1073.e8. doi:10.1016/j.cjca.2015.03.018. ISSN 0828-282X.
- ↑ 12.0 12.1 Y-Hassan, Shams; Henareh, Loghman (2013). "Spontaneous coronary artery dissection triggered post-ischemic myocardial stunning and takotsubo syndrome: two different names for the same condition". Cardiovascular Revascularization Medicine. 14 (2): 109–112. doi:10.1016/j.carrev.2012.11.005. ISSN 1553-8389.
- ↑ Y-Hassan, Shams; Themudo, Raquel; Maret, Eva (2017). "Spontaneous coronary artery dissection and takotsubo syndrome: The chicken or the egg causality dilemma". Catheterization and Cardiovascular Interventions. 89 (7): 1215–1218. doi:10.1002/ccd.26956. ISSN 1522-1946.
- ↑ Y-Hassan, Shams; Böhm, Felix (2016). "The causal link between spontaneous coronary artery dissection and takotsubo syndrome: A case presented with both conditions". International Journal of Cardiology. 203: 828–831. doi:10.1016/j.ijcard.2015.11.047. ISSN 0167-5273.
- ↑ Yalta, Kenan; Ucar, Fatih; Yilmaztepe, Mustafa; Ozkalayci, Flora (2016). "Tako-tsubo cardiomyopathy and spontaneous coronary artery dissection: A subtle association with prognostic implications?". International Journal of Cardiology. 202: 174–176. doi:10.1016/j.ijcard.2015.08.152. ISSN 0167-5273.
- ↑ Madias, John E. (2015). "On a Plausible Association of Spontaneous Coronary Artery Dissection and Takotsubo Syndrome". Canadian Journal of Cardiology. 31 (11): 1410.e1. doi:10.1016/j.cjca.2015.07.720. ISSN 0828-282X.
- ↑ Madias, John E. (2017). "A Possible Amphidromic Relation Between Spontaneous Coronary Artery Dissection and Takotsubo Syndrome". The American Journal of Cardiology. 120 (3): e69. doi:10.1016/j.amjcard.2016.10.008. ISSN 0002-9149.
- ↑ Pelliccia, Francesco; Kaski, Juan Carlos; Crea, Filippo; Camici, Paolo G. (2017). "Pathophysiology of Takotsubo Syndrome". Circulation. 135 (24): 2426–2441. doi:10.1161/CIRCULATIONAHA.116.027121. ISSN 0009-7322.