The Young Heart Tears Easily Apart: A Case Report of Spontaneous Coronary Artery Dissection

Abstract

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS), seen mostly in young females. The rarity and limited knowledge of the disease make its management challenging. Prompt diagnosis of the condition is extremely important to decrease both long-and short-term complications. Treatment options depend on hemodynamic stability and the location of the dissection-with more distal lesions treated more conservatively as opposed to proximal lesions which are treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The following are the two cases with different presentation, management and outcomes.Our first patient was a 35-year-old woman with no medical history who presented with acute, anginal pain, diaphoresis and palpitations. She was hemodynamically stable on presentation, with work-up significant for electrocardiogram (ECG) with sinus bradycardia, ST elevation in leads V1-V6, and elevated troponin level of 4 ng/ml. There was no evidence of a pulmonary embolism on computed tomography (CT) of the chest. A coronary angiogram showed 100% dissection of the proximal to mid-left anterior descending (LAD) artery. Attempts to place a stent in the proximal to mid LAD were unsuccessful as the true lumen of the LAD was not accessible. The patient became hemodynamically unstable, and an emergent CABG was done, restoring blood flow. The patient recovered during her hospital stay and was discharged with dual antiplatelet therapy (DAPT), beta-blockers, and atorvastatin.The second patient was a 28-year-old woman, with a history of hypertension who presented with anginal chest pain. Workup showed ECG with minimal ST elevations in anteroseptal leads, with elevated troponin level to 0.71 ng/ml. Coronary angiogram showed 40-50% stenosis of the mid LAD with an aneurysmal segment. An echocardiogram showed no evidence of wall motion abnormalities, and she had a normal left ventricular ejection fraction (LVEF). She was discharged home the next day, on medical management. After two days, she returned to the hospital with similar complaints, with work-up significant for ECG with nonspecific ST-T abnormality, and troponin level which peaked at 2.22 ng/ml. She was started on a heparin drip, and a repeat left heart catheterization revealed type 2 dissection of the mid to distal LAD, with intravascular ultrasound showing a fractional flow reserve of 0.76. She was discharged home on DAPT, beta-blocker, calcium channel blocker (CCB), and atorvastatin, with close cardiology follow up. These two cases highlight the importance of keeping in mind the possibility of SCAD, especially when relatively healthy young women present with anginal symptoms. Early diagnosis of the condition and prompt management are extremely important to ensure favourable outcomes. The two cases also describe the coronary angiogram findings in SCAD, and the different strategies employed in the management of this condition.

Spontaneous Coronary Artery Dissection in Young Patients: A Case Series and Review of Current Management Algorithm

“…Coronary angiography is the first line of investigation with some limitations in precisely localizing the dissection entry point and identifying the true and false lumen. When coronary angiography can’t make the diagnosis, intracoronary imaging like IVUS and OCT can be used, as these imaging modalities give a more detailed analysis of the lesion [ 1 , 4 , 5 , 7 , 12 , 14 ]. However, intracoronary imaging may not be feasible in each case, particularly in those with severe tortuosity or when it involves more distal small-caliber arteries.…”

“…Stent placement or CABG is considered for patients with more proximal dissection, hemodynamic instability, dynamic ST-segment changes, and ventricular arrhythmias [ 4 , 12 ]. PCI is associated with the risk of dissection extension, guidewire passage into the false lumen, and major side branch restriction or blockade by hematoma [ 1 , 14 ].…”

Unusual Finding of Type 1 and Type 2 Spontaneous Coronary Artery Dissection in a Multiparous Female: A Case Report

“…The first involves an intimal tear which results in blood collection in the intimal space from the endoluminal space forming false lumen which is termed as "inside-out". The second mechanism involves rupture of the vasa vasorum resulting in false lumen filled with hematoma which has also been referred to as "outside-in" [1,2]. Both these mechanisms lead to luminal encroachment and narrowing resulting in subsequent coronary artery obstruction causing myocardial ischemia and infarction.…”

“…Other notable associated risk factors include systemic inflammatory disorders, multiparity, oral contraceptives, pregnancy, history of migraine, mechanical and emotional stressors [11]. Mechanical stressors including strenuous exercise have been classically associated with SCAD in males whereas emotional stressors are linked to SCAD in females [2]. A study conducted by Tweet et al reported that the incidence of pregnancy-related SCAD is more in multiparous women [12].…”

Double Trouble - Spontaneous Coronary Artery Dissection of the Left Anterior Descending and Posterior Descending Arteries in a Right Dominant Circuit: A Case Report

“…The outside-in mechanism, considered to be the most common form, suggests that the intramural hematoma forms within the vessel due to rupture of the vasa vasorum. The inside-out mechanism proposes the reverse in that the tear occurs first leading to a false lumen between the media and tunica intima [ 9 ].…”