Case Presentation: A 45-year-old Caucasian female with insignificant medical history presented to a community medical center with typical 8/10 left-sided chest pain radiating to left arm. It resolved with sublingual nitroglycerin, only to present with a similar episode next morning. During a Bruce stress echocardiogram, she reported chest discomfort and dyspnea collaborative with electrocardiographic (EKG) and echocardiographic changes suggestive of ischemia. Subsequently, she was transferred to our tertiary care center for further management. At presentation, patient was chest pain-free, with EKG demonstrating left axis deviation, biphasic T-waves, and T-wave inversion in V1 and V2. Cardiac Troponin-I was marginally elevated at 0.24 ng/ml. Subsequent coronary angiogram demonstrated proximal right coronary artery (RCA) dissection, which was treated with drug eluting stent. Her post-procedural course was complicated by acute total occlusion of stent, for which she received balloon angioplasty and two additional RCA stents. She made an uneventful recovery, and was dismissed home with no acute issues on subsequent outpatient follow-up one month later.
Discussion: Spontaneous coronary artery dissection (SCAD) is a rare coronary artery disease with annual angiographic incidence of 0.7-1.1%, affecting females (82%), at mean age of 42.6 years. Its presentation includes a spectrum of manifestations such as unstable angina, non-ST elevation myocardial infarction, ST-elevation myocardial infarction, ventricular fibrillation and sudden cardiac death. It is commonly associated with female gender, Caucasian race, post-menopausal status, depression, migraine, postpartum status and extreme physical activity in men. Recent literature reports concomitant prevalence of fibromuscular dysplasia in non-coronary distribution. Management of SCAD depends on angiographic findings and hemodynamic status. Treatment options include medical therapy, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Conservative strategy similar to usual acute coronary syndrome can be pursued when patient is clinically stable without ongoing ischemia and/or when the vessel involved is small-sized and distal. If a pronounced dissection persists in a major vessel after medical treatment or when there is epicardial coronary flow impairment and/or ongoing ischemia, PCI or CABG should be considered. ‘Conservative’ management strategy, defined as selecting revascularization only for patients with ongoing or recurrent ischemia, is associated with an excellent long-term prognosis. Its 10-year rates of recurrence, mortality and major adverse cardiovascular events are 17%, 29% and 47% respectively.
Conclusions: SCAD is a rare but potentially lethal cause of acute coronary syndrome and should be considered among differential diagnosis of chest pain especially in young females. Known SCAD patients should be managed with vigilance because of significantly high morbidity and mortality.
To cite this abstract:Nawaz M, Mansour G, Ayan M, Sundaragiri P, Biddle W. Spontaneous Coronary Artery Dissection: A Rare Cause of Myocardial Infarction. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 633. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/spontaneous-coronary-artery-dissection-a-rare-cause-of-myocardial-infarction/. Accessed May 27, 2019.