Concomitant presentation of spontaneous coronary artery dissection with Takotsubo syndrome: a case report

Abstract

Background: Spontaneous coronary artery dissection (SCAD) is still an underdiagnosed condition that requires a detailed assessment of angiographic signs. It also shares similar clinical presentations with Takotsubo syndrome (TTS). The concomitant presentation of SCAD with TTS is a possible occurrence, making it difficult for clinicians to treat and manage.

Case summary: This study included a 49-year-old woman with retrosternal chest pain who was admitted to the emergency department. Coronary angiography indicated Type 2A SCAD involving the middle part of the left anterior descending artery, while the left ventriculography indicated a typical left ventricular apical ballooning compatible with TTS. A conservative approach to the management of SCAD was observed. After a 3-month follow-up, the control coronary angiography showed a complete angiographic resolution. The results of the transthoracic echocardiogram (TTE) and cardiac magnetic resonance revealed a complete normalization of the pathological features. The patient remained asymptomatic and showed no recurrence of chest pain.

Discussion: Although TTS and SCAD are commonly observed in patients who share certain characteristics (women, without atheromatous terrain, stress-related factors), it is difficult to establish a pathophysiological link between them. This observation confirms the non-random association of two rare entities of myocardial infarction with no obstructive coronary arteries. Although TTS can be easily diagnosed via non-invasive imaging, the diagnosis of SCAD is more difficult. The findings of this study suggest a concomitant presentation between SCAD and TTS. Although the treatment approach to SCAD is usually conservative, severe forms of this disease require early diagnosis and appropriate treatment.

Keywords: Acute coronary syndrome; Case report; Left ventricular apical ballooning; Spontaneous coronary artery dissection; Takotsubo syndrome.

Figure 1

Twelve-lead electrocardiogram performed upon admission (A) indicated sinus tachycardia, normal axis, and no ST-T change. (B) 24 h post-admission: T-wave inversions in lead V2–V6 with QTc prolongation. (C) At 3 months.

Figure 2

(A and B) Coronary angiography in the right anterior oblique cranial view indicated Type 2A spontaneous coronary artery dissection based on the classification system published by Saw et al. involving the middle portion of the left anterior descending artery with a ‘stick insect’ appearance bordered by normal artery segment (white arrows) (C and D). Control angiography at 3M showed complete resolution of the previous pathological findings (black arrows). (A and C) Face cranial view. (B and D) Left anterior oblique cranial view.

Figure 3

(A) Cine cardiac magnetic resonance two-chamber showed typical apical ballooning in end-systole. (B) Late gadolinium enhancement excluded myocardial necrosis in the dyskinetic anterior wall. (C) T1 mapping revealed a focal elevation in the T1 values of the distal anterior, apical, and distal inferior walls (T1 1300 ms vs. 1000 ms in other myocardial regions). (D) T2 mapping showed an elevation in the T2 values of the apical wall (60 ms vs. 50 ms in the other territories) indicating myocardial oedema. At follow-up, Cine cardiac magnetic resonance imaging in the vertical long axis (E and F) and four-chamber view (H and I) showed a normalization of global left ventricular systolic function. (G) T1 cartography in the short axis showed a homogeneous aspect with normal T1 at 1030 ms. (J) Late gadolinium enhancement-cardiac magnetic resonance imaging could not detect significant late gadolinium enhancement.