Case Presentation: 36 year old female with no past medical history presented to hospital with acute onset of severe midsternal chest pain radiating to back, throat and jaw that lasted approximately 20 minutes and resolved spontaneously. Her EKG showed T wave inversion in inferior leads with elevated troponin for which she was started on heparin drip for management of NSTEMI. Urgent cardiac catheterization was remarkable for right coronary artery showing diffuse stenosis. A guidewire was advanced that entered false lumen and subsequent angiogram showed extensive coronary artery dissection extending from proximal segment throughout the entire mid segment. The patient developed severe chest pain with associated inferior ST segment elevation and was treated with three overlapping drug eluting stents that resolved symptoms and EKG changes. She was diagnosed with spontaneous coronary artery dissection (SCAD) and had subsequent hospitalizations for chest pain that showed SCAD of left anterior descending artery on angiogram that was managed conservatively. She was referred to rheumatology for further work up of SCAD.
Discussion: SCAD is non-traumatic, non-atherosclerotic etiology of acute coronary syndrome (ACS) and sudden cardiac death in young patients with female preponderance. Proposed mechanisms include intimal tear leading to flap formation or rupture of vasa vasorum leading to medial hemorrhage. Dissections usually heal spontaneously however refractory ischemia may need revascularization. SCAD has strong association with fibromuscular dysplasia and work up for etiology should be undertaken. Recurrence of disease is possible.
Conclusions: Young patients with chest pain and without risk factors for coronary artery disease are typically placed in low risk ACS bracket, however this can lead to false sense of reassurance. SCAD should be considered in young patients with chest pain and alarming history. These patients should have family screening and complete evaluation for etiology of SCAD.