Case Presentation: 19-Year-old ,African American, female with significant medical history of hypertension, Uncontrolled Diabetes Mellitus, presents with chest pain for 24 hr. Pain was sub-sternal, pressure like,7/10,radiating to right arm and in between the shoulder blades, persistent ,precipitated by drinking alcohol the night before ,associated with Shortness of breath and palpitations. Patient had a history of binge drinking overnight. She is also a regular tobacco and marijuana smoker. No significant family history. No known Drug Allergies. History of non-compliance with medications for her existing medical conditions.On exam, She was afebrile, Normotensive, tachycardiac with HR 105-110, RR 18/min, Saturating well above 95% at Room air. Pt appeared obese, was in moderate distress due to chest pain and her cardiopulmonary exam was unremarkable.EKG on presentation was consistent with sinus rhythm, 84 bpm, with ST-T segment elevation in anteroseptal and lateral leads with Q waves in V1 and V2. Significant labs: troponin elevated to >25,leucytosis WBC 15.9,Blood Glucose 375,Anion gap 16, BHB 4.26, bicarbonate 17,HbA1C:12.4,Urine Drug screen positive for Cannabinoids. CXR was normal.In-hospital, code STEMI was called and patient was taken to Cath lab immediately. Cardiac catheterization with Right radial access was performed. LAD was 100%occluded at ostium.Attempted to wire and angioplasty of the vessel, able to pass the wire across the proximal occlusion but in mid LAD, it was difficult to rotate the tip, suggesting the wire to be in false lumen, angioplasty with balloon was unsuccessful with no improvement or recanalization of the vessel.With significant concern for SCAD, IVUS was performed, which demonstrated mild atherosclerotic disease and almost totally occlusive dissection flap. High suspicion for SCAD was made due to clinical presentation and inability to recanalize with angioplasty and areas of false lumen seen in IVUS.Patient was transferred to higher center and underwent successful intra-aortic balloon pump placement. post procedure echo showed EF 21-25%, with apex, apical anterolateral and septal segments akinesis. CT surgery consultation was done for possible need for CABG. Clinical decision to continue with conservative medical management was done.Patient required medical management, clinically improved after about 2 weeks of hospital stay. She was subsequently discharged home with cardiac rehabilitation and cardiology follow up. Follow up ECHO a month later shows significant improvement in EF (36-40%)and wall motion abnormality.
Discussion: Spontaneous Coronary artery Dissection ( SCAD)is a rare cause of Acute Coronary syndrome and usually occurs in previously healthy women with minimal cardiac risk factors. It can be a cause of Sudden cardiac death as well significant cardiac morbidity and mortality. High Suspicion of disease in young women presenting with ACS is very important as early recognition and appropriate management can prevent the high mortality associated with the condition.
Conclusions: Spontaneous Coronary artery Dissection ( SCAD) is an uncommon cause of chest pain and Acute Coronary syndrome that needs high clinical suspicion and timely management.Hospitalists are at the forefront of management of a vast number of chest pain cases and can create a huge impact in the mortality of these young women who usually don’t have many cardiac risk factors.These type of cases present a diagnostic and management challenge to hospital medicine.