Cardiovascular Disease: Student/Resident Case Report Poster - Cardiovascular Disease I |

Spontaneous Dissection of the Left Main Coronary Artery in a Young Woman FREE TO VIEW

Abdullah Shahid, MBBS; Afeefa Shahnawaz, MBBS; Sheikh Saleem, MBBS; Edward Bischof, MBBS; Patrick McNulty, MBBS
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Mary Imogene Bassett Hospital, Cooperstown, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):86A. doi:10.1016/j.chest.2016.08.094
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SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Emotional stress is known to precipitate myocardial infarction but mechanisms remain uncertain. We present a case of a young woman who presented with ST elevation myocardial infarction and cardiogenic shock precipitated by acute emotional stress and found to have spontaneous dissection of the left main coronary artery (LMCA) without evidence of atherosclerosis.

CASE PRESENTATION: A 45 year old woman with a history of anxiety experienced severe substernal chest pain, diaphoresis and syncope immediately after an emotionally stressful encounter at work. On presentation to the ER thirty minutes later, she appeared pale and lethargic with cold extremities. Her initial blood pressure was 91/71 mmHg with heart rate of 104. EKG showed ST segment elevation in leads aVL and V2 - V5. While in the ER her blood pressure dropped to 70/40 mmHg and she developed severe hypoxia. She was intubated and was taken to cardiac catheterization lab emergently where her systolic blood pressure was 40 mmHg. An intra-aortic balloon pump (IABP) was placed and she was started on a dopamine infusion. Coronary angiography showed tiny, thread like LMCA which was immediately stented with a drug eluting stent. The left anterior descending, left circumflex and right coronary arteries were unremarkable. Subsequent intra-vascular ultrasound showed dissection of the LMCA and confirmed the absence of atherosclerosis. An echocardiogram done the next day showed an ejection fraction (EF) of 20 - 25%. She was evaluated for urgent heart transplant but recovered after several days of mechanical ventilation, IABP and inotrope support. She received an implantable cardioverter defibrillator for primary prevention of sudden cardiac death. One year later her EF remains 20 - 25% and she continues to have NYHA class ll symptoms.

DISCUSSION: Spontaneous coronary artery dissection is a very rare cause of acute coronary syndrome (ACS) representing 0.1 - 0.4% of the cases, mostly women. Spontaneous dissection involving the LMCA is rarely diagnosed and is assumed to be incompatible with survival. Indeed, a literature search shows fewer than 25 cases diagnosed in patients who were still alive. The pathogenesis is poorly understood, however potential predisposing factors include connective tissue disorders, fibromuscular dysplasia and post-partum state. It is notable that while spontaneous dissection of normal coronary arteries has been reported in association with strenuous exertion, this case suggests an association with pure emotional stress. Optimal management is uncertain given the rarity of cases but there have been reports of treatment with conservative management, percutaneous coronary intervention, fibrinolytic therapy and CABG.

CONCLUSIONS: Spontaneous dissection of a coronary artery should be considered in young women who present with ACS without any risk factors for coronary artery disease.

Reference #1: Nishiguchi T, et al. Prevalence of SCAD in patients with ACS. Eur Heart J Acute Cardiovasc Care 2013.

DISCLOSURE: The following authors have nothing to disclose: Abdullah Shahid, Afeefa Shahnawaz, Sheikh Saleem, Edward Bischof, Patrick McNulty

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