Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndrome in young otherwise healthy patients with a striking predilection for the female sex. We describe a patient who underwent coronary angiography for acute coronary syndrome and was found to have spontaneous dissection of Right Coronary Artery (RCA). A 55‐year‐old Hispanic male, with no significant past medical history, presented with retrosternal pressure‐like chest pain radiating to the left arm. On examination, he had mildly elevated pulsatile jugular venous distension and the lungs were clear. The patient remained stable hemodynamically. EKG showed ST segment depression in leads 11,111, aVF, V3‐V6. Labs showed raised elevated cardiac biomarkers. Coronary arteriography performed 3 hours after the episode revealed a dissection involving the middle segment of right coronary artery. Left coronary system was normal. Because of spiral form of dissection, the TlMl 3 flow grade, and stable hemodynamic status, our patient was treated medically and repeat coronary angiography 6 months later was planned.
SCAD is an extremely uncommon cause of acute coronary syndrome with an incidence of 0.1% among patients undergoing cardiac catheterization. More than 70% of the reported cases are diagnosed postmortem. Typically, SCAD involves the left coronary system (75% of all SCAD) and is usually reported in women. In men, SCAD tends to involve the right coronary artery. Pathophysiology is probably heterogeneous including atherosclerosis, connective tissue disorders, vasculites, oral contraceptives and the peripartum period. In patients with SCAD who do not have ongoing symptoms or hemodynamic instability, medical management can be considered. The use of thrombolytic is controversial, with both a theoretical and reported risk of increasing the propagation of dissection. In patients with ongoing ischemia or hemodynamic instability with single vessel SCAD, percutaneous coronary angioplasty and stenting is recommended. In patients with mullivessel disease, left main coronary artery disease, or patients unresponsive to other options, coronary artery bypass grafting is recommended if feasible.
The true incidence of SCAD is underestimated since it may lead to death in the preclinical phase and dissections of the coronary arteries are often difficult to recognize. Considering the fact that the decisions for coronary angiogram in the setting of acute coronary syndromes are based on pretest probability and TIMI risk stratification, the consequences of SCAD can be devastating because majority of such patients lack the conventional risk factors for coronary artery disease
S. Butt, Mount Sinai School of Medicine (Jersey City Medical Center), employment; S. Penkulinti, Mount Sinai School of Medicine (Jersey City Medical Center), employment; F. Aziz, Mount Sinai School of Medicine (Jersey City Medical Center), employment; J. Riaz, Mount Sinai School of Medicine (Jersey City Medical Center), employment; N. Majeed, Mount Sinai School of Medicine (Jersey City Medical Center), employment.