Is Anticoagulant Necessary in Patients with Coronary Artery Ectasia Presenting with Acute Coronary Syndrome? A Systematic Review of Case Reports

Abstract

Coronary artery ectasia is found in 3 to 8% of patient's undergoing angiography and may sometimes induce acute myocardial infarction. Some articles reported a recurrence of acute coronary syndrome (ACS) in the presence of coronary artery ectasia (CAE). Our study aims to summarize the latest evidence on whether the use of anticoagulant in addition to SAPT/DAPT (single antiplatelet/dual antiplatelet) treating ACS with CAE patients is necessary. Since the trials concerning our objectives were scarce, we pooled case reports/series. We performed a comprehensive search on case reports/series on coronary artery ectasia that presented with acute coronary syndrome published until March 2019. We collected 13 cases from 11 reports. Out of 13 patients, 5 (38.5%) took DAPT only without anticoagulant and 8 (61.5%) took anticoagulant ± DAPT. Three out of five (60%) who took DAPT only, experienced recurrences at 1st and 2nd months' follow-up. The other two (40%) was uneventful at a mean of two months' follow-up. Eight patients who took anticoagulant were uneventful for a mean of 8.4 months. Those who took anticoagulant were at lower risk of experiencing ACS recurrence (p = 0.035). Two of the patients who experienced recurrence became 6 and 12 months free after optimal anticoagulation. The author of this study proposed that anticoagulant must be considered should SAPT/DAPT failed to provide adequate protection to the recurrence of ACS, especially in CAE patients who did not have other obvious stenotic lesions. However, the evidence is weak since this study only pooled case reports/series.

Keywords

acute coronary syndrome - coronary artery ectasia - recurrence - antiplatelet - anticoagulant - antithrombotic - triple therapy

• References

• 1 Choi HJS, Luong C, Fung A, Tsang TSM. ST-elevation myocardial infarction in coronary ectasia: a case report. Diseases 2018; 6 (04) 104
• 2 Boles U, Rakhit R, Shiu MF, Patel K, Henein M. Coronary artery ectasia as a culprit for acute myocardial infarction: review of pathophysiology and management. Anadolu Kardiyol Derg 2013; 13 (07) 695-701
• 3 Hartnell GG, Parnell BM, Pridie RB. Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients. Br Heart J 1985; 54 (04) 392-395
• 4 Mavrogeni S. Coronary artery ectasia: from diagnosis to treatment. Hellenic J Cardiol 2010; 51 (02) 158-163
• 5 Papadakis MC, Manginas A, Cotileas P. , et al. Documentation of slow coronary flow by the TIMI frame count in patients with coronary ectasia. Am J Cardiol 2001; 88 (09) 1030-1032
• 6 al-Harthi SS, Nouh MS, Arafa M, al-Nozha M. Aneurysmal dilatation of the coronary arteries: diagnostic patterns and clinical significance. Int J Cardiol 1991; 30 (02) 191-194
• 7 Devabhaktuni S, Mercedes A, Diep J, Ahsan C. Coronary artery ectasia-a review of current literature. Curr Cardiol Rev 2016; 12 (04) 318-323
• 8 Rab ST, Smith DW, Alimurung BN, Rab R, King III SB. Thrombolytic therapy in coronary ectasia and acute myocardial infarction. Am Heart J 1990; 119 (04) 955-957
• 9 Mrdović I, Jozić T, Ašanin M, Perunicić J, Ostojić M. Myocardial reinfarction in a patient with coronary ectasia. Cardiology 2004; 102 (01) 32-34
• 10 Perlman PE, Ridgeway NA. Thrombosis and anticoagulation therapy in coronary ectasia. Clin Cardiol 1989; 12 (09) 541-542
• 11 Tomioka T, Takeuchi S, Ito Y, Shioiri H, Koyama J, Inoue K. Recurrent acute myocardial infarction in a patient with severe coronary artery ectasia: Implication of antithrombotic therapy. Am J Case Rep 2016; 17: 939-943
• 12 Latt H, Aung S, Kyaw K, Seher R. Coronary artery ectasia presenting with acute inferior wall myocardial infarction in a young adult. J Community Hosp Intern Med Perspect 2017; 7 (04) 262-264
• 13 Lima B, Varma SK, Lowe JE. Nonsurgical management of left main coronary artery aneurysms: report of 2 cases and review of the literature. Tex Heart Inst J 2006; 33 (03) 376-379
• 14 Furugen M, Takagawa Y. Staged interventional management of a massive thrombus related to coronary artery ectasia in acute coronary syndrome. Cardiovasc Interv Ther 2012; 27 (01) 57-61
• 15 Tuncer C, Sokmen G, Sokmen A, Suner A. Diffuse coronary ectasia and intracoronary thrombus involving left circumflex coronary artery and presenting as acute coronary syndrome: report of two cases. Int J Cardiol 2008; 128 (01) e25-e27
• 16 Okada T, Endo A, Ito S. , et al. Acute coronary syndrome in a puerperal patient with coronary artery ectasia due to a coronary artery fistula. Intern Med 2016; 55 (18) 2635-2638
• 17 Damay V, Pranata R, Wiharja W. Recurrent acute coronary syndrome in a patient with right coronary artery ectasia: a case report. J Med Case Reports 2019; 13 (01) 78
• 18 Liu J, Sukhova GK, Yang J-T. , et al. Cathepsin L expression and regulation in human abdominal aortic aneurysm, atherosclerosis, and vascular cells. Atherosclerosis 2006; 184 (02) 302-311
• 19 Erden I, Erden EÇ, Özhan H, Karabulut A, Ordu S, Yazici M. Outcome of primary percutaneous intervention in patients with infarct-related coronary artery ectasia. Angiology 2010; 61 (06) 574-579
• 20 Hara T, Fukuda D, Tanaka K. , et al. Rivaroxaban, a novel oral anticoagulant, attenuates atherosclerotic plaque progression and destabilization in ApoE-deficient mice. Atherosclerosis 2015; 242 (02) 639-646
• 21 Eikelboom JW, Connolly SJ, Bosch J. , et al; COMPASS Investigators. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med 2017; 377 (14) 1319-1330
• 22 Fabjan A, Bajrović FF. Novel direct anticoagulants and atherosclerosis. Curr Vasc Pharmacol 2019; 17 (01) 29-34