Critical Care: Student/Resident Case Report Poster - Critical Care II |

Spontaneous Multi-Vessel Coronary Artery Dissection FREE TO VIEW

Michael Goldfarb, MD
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McGill University, Cote St Luc, QC, Canada

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

Chest. 2016;150(4_S):389A. doi:10.1016/j.chest.2016.08.402
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Spontaneous multi-vessel coronary artery dissection is exceedingly rare. The optimal management strategy is currently unknown.

CASE PRESENTATION: A 50-year-old man with no past medical history presented with a 9 month history of intermittent chest discomfort on exertion. Initial physical exam was unremarkable and cardiac enzymes were not elevated. ECG showed 2 millimetre convex anterior ST elevation with reciprocal ST depressions. Coronary angiography showed dissection of the proximal left anterior descending artery (LAD) (figure 1), the ostial circumflex artery extending into the left main coronary artery and the entire right coronary artery. There was no aortic root disease. The left ventricular ejection fraction was 20-25%. The Heart Team decided not to attempt percutaneous intervention, nor intervene surgically due to poor distal targets. The hospital stay was complicated by episodes of pulseless ventricular tachycardia requiring emergent defibrillation. A repeat angiogram showed partial recanalization of the LAD. Percutaneous intervention was again discussed but not pursued. The patient improved with supportive management and was discharged home with good functional status. Subsequent serologic and genetic testing for connective tissue disorders did not reveal an identifiable cause.

DISCUSSION: Spontaneous Coronary Artery Dissection (SCAD) occurs more frequently in women (82%) and has a prevalence of only 0.2% on cardiac catheterization series.1, 2 SCAD is associated with connective tissue disorders such as fibromuscular dysplasia and Ehlers-Danlos. Multivessel dissection occurs in only 23% of cases.2 STEMI is the most common presentation (49%), but chronic, stable ischemic symptoms or pulseless cardiac arrest, as was seen in our patient, may occur as well. Clinical presentation usually ranges from typical angina symptoms to STEMI to sudden cardiac death. PCI is associated with high rates of complications and may be deferred, as in this case, since in-hospital mortality is low regardless of initial treatment strategy. Spontaneous resolution of the dissected coronaries is commonly seen if follow-up coronary angiography is performed. Thus, our patient had an uncommon presentation of a rare disease: a male with multi-vessel involvement of unknown etiology presenting with chronic stable ischemic symptoms which progressed to pulseless cardiac arrest.

CONCLUSIONS: This case demonstrates that medical management is often an acceptable treatment strategy for multi-vessel SCAD.

Reference #1: Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European Journal of Cardio-Thoracic Surgery. 2009;35:250-4.

Reference #2: Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012;126:579-88.

DISCLOSURE: The following authors have nothing to disclose: Michael Goldfarb

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