Case Presentation: A 40 year-old female with history of pulmonary embolism during pregnancy presented with sudden onset of substernal chest pain and shortness of breath, which began an hour after she finished a rowing class. She also experienced nausea and left hand numbness and tingling. On presentation, vital signs were within normal limits and physical examination was unremarkable. EKG revealed ST elevation in V2 and ST depression in leads II, III and AVL (Fig. 1). Bedside ultrasound revealed anterior wall motion abnormality. Patient received aspirin 325mg PO, heparin IV bolus and drip, and clopidogrel 300mg PO load. She was taken for emergent cardiac catheterization, which revealed dissection of the mid left anterior descending coronary (LAD). A drug eluting stent (DES) was placed in the artery with normalization of flow. The remainder of the coronary arteries showed no obstruction. Post-catheterization EKG showed normalization of ST segments (Fig. 2), repeat echocardiogram showed normal left ventricular systolic size and function. Blood work was remarkable for normal lipid profile and negative ANA, ANCA panel, and rheumatoid factor. Urine pregnancy was negative. Troponin peaked was 7.7ng/ml. Patient was discharged on dual antiplatelet agents, low dose B-blocker and a statin.
Discussion: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS), accounting for less than 0.5% of total cases. SCAD is usually seen in young women in the peripartum state. The underlying mechanism is not well described; it is theorized that an intramural hematoma creates a false lumen, which compresses the true lumen of the coronary artery, resulting in myocardial ischemia. Risk factors linked to SCAD include severe exertion, postpartum status, life-threatening arrhythmias, connective tissue disorders, and inflammatory diseases. Clinical presentation varies from unstable angina to sudden cardiac death; severity of presentation correlates with the degree of dissection. Coronary angiography with possible percutaneous coronary intervention (PCI) are the diagnostic and therapeutic modalities of choice. Recurrence rate of having a new cardiovascular event is up to 10%.
Conclusions: SCAD as an etiology of ACS should be considered in patients without traditional cardiovascular risk factors, as well as in specific populations including peripartum women, and patients with connective tissue disorders or inflammatory states. Mortality rate is as high as 75% and diagnosis is usually post-mortem. Early recognition with appropriate and rapid intervention is critical for survival.
To cite this abstract:Olazagasti C, Bernabe C, Velazquez AI, Harrington M. “Tear It Up! Exercise Induced Coronary Artery Dissection”. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 715. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/tear-it-up-exercise-induced-coronary-artery-dissection/. Accessed May 22, 2019.