Spontaneous coronary artery dissection and acute myocardial infarction in women

Abstract

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as a cause of acute coronary syndrome, acute myocardial infarction, and sudden death in young patients, particularly women, presenting to the emergency department with chest pain. It is the most common cause of nonatherosclerotic coronary artery disease in women <50 years of age. Current guidelines for SCAD management come from case series that have demonstrated low success rates and high rates of complications with percutaneous coronary intervention. Expert consensus suggests conservative care, and observation is preferred in many patients. However, patients with ongoing symptoms of cardiac ischemia or hemodynamic or electrical instability with compromised myocardial perfusion remain challenging. With this case report, we aim to increase awareness of SCAD and critical aspects of its diagnostic and therapeutic approach. Further investigation is needed to clarify the ideal candidates for revascularization to optimize outcomes and limit morbidity and mortality.

Keywords: Acute myocardial infarction; coronary artery dissection; spontaneous coronary artery dissection.

Figure 1.

Initial ECG on arrival to the emergency department showing a nonspecific T wave abnormality with T wave inversion in the inferior (II, III, aVF) and anterolateral (V5, V6) leads. Q waves in the septal leads (V1, V2) are suggestive of age-indeterminate septal infarct.

Figure 2.

Repeat ECG at the time of increased chest pain. ST elevation is now present in the septal leads (V1, V2) with ST depression in the inferior and anterolateral leads (I, II, aVF, V5, and V6).

Figure 3.

Static coronary angiogram showing SCAD in the left anterior descending coronary artery, starting in the proximal portion of the vessel and leading to 90% mid stenosis with involvement of two diagonal branches. The left circumflex artery had severe distal dissection and the right coronary artery had dissection in the mid portion of the vessel leading to moderate narrowing.