Cardiology fellow HCA Florida Trinity Hospital Land O Lakes, Florida, United States
Disclosure(s):
Arish Maknojia, MD: No financial relationships to disclose
Background: Spontaneous Coronary Artery Dissection (SCAD) is an atraumatic separation of the coronary arterial wall and is a rare cause of myocardial infarction. It primarily affects females under the age of 50. We present a unique case of a 41-year-old female with SCAD that was initially missed.
Methods: A 41-year-old female with a past medical history of hypertension, hyperlipidemia, migraines, and anxiety presented to the emergency department with chest pain that began following an episode of nausea and vomiting. On arrival, she was tachycardic, but her physical examination was otherwise unremarkable. An initial EKG showed sinus tachycardia without any concerning ST-T wave changes. D-dimer was negative. The initial troponin was negative; however, a repeat value two hours later was elevated at 8,017. She received a dose of nitroglycerin in the ED, which resolved her chest pain. The patient was started on aspirin and a heparin drip. Overnight, the patient experienced recurrent chest pain. A repeat EKG again showed sinus tachycardia with no acute ST-T wave abnormalities. A subsequent troponin was markedly elevated at 24,527. She was taken for a left heart catheterization (LHC) the following morning, which showed a moderate caliber LAD with 50% mid-vessel stenosis that tapered quickly. An echocardiogram revealed a preserved ejection fraction (EF) of 55–60% with mid to distal anterior septal hypokinesis.
Outcome: Due to the discrepancy between the angiographic findings and the regional wall motion abnormality seen on echocardiogram, the case was discussed with interventional cardiology. After thorough discussion, it was concluded that the patient most likely had type 2B SCAD—characterized by an abrupt, diffuse narrowing of the vessel that extends to the distal tip of the artery. This correlated with the regional wall motion abnormality noted on echo. As per the ACC/AHA SCAD management algorithm, the decision was made to manage the patient conservatively. She was continued on aspirin and started on clopidogrel, a statin, and a beta-blocker.
Conclusion: This case highlights a rare and often underdiagnosed condition—Spontaneous Coronary Artery Dissection. Although our patient had a favorable outcome, early recognition of SCAD is crucial to guide appropriate management and prevent potential complications.
