199: GETTING DOWN TO THE HEART OF IT: A CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD)

Abstract

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare but fatal diagnosis that can often be misdiagnosed in young and middle-aged female patients who present with acute Myocardial Infarction-like symptoms without any classic cardiovascular risk factors. Description: A middle-aged female with no known medical history presented after she acutely became lightheaded, vomited and had new-onset chest pain. Upon arrival she was obtunded, so she was intubated. Her EKG showed 5mm ST elevation in the inferolateral leads, and her chest x-ray showed mediastinal widening. She was taken for a Computed Tomography (CT) scan, and her CT Chest was negative for dissection. She was then taken for a coronary angiogram where she underwent Percutaneous Coronary Intervention (PCI). During her angiogram, she was found to have a Type 1 SCAD. Her angiogram was complicated by her going into Ventricular Fibrillation (VF) for which she underwent Direct Current Cardioversion and returned to Normal Sinus Rhythm. She had 2 Drug Eluting Stents placed to the Ostial Proximal Right Coronary Artery and was started on norepinephrine due to cardiogenic shock. As she started to stabilize, she was weaned off norepinephrine and propofol and extubated. Further workup showed during a CT Angiography Head and Neck there was beading and undulation noted of the left mid-Internal Carotid Artery which could be indicative of Fibromuscular Dysplasia (FMD). Her SCAD was additionally managed with aspirin, ticagrelor, atorvastatin, and metoprolol with plans to closely monitor her FMD in the outpatient setting due to her risk for recurrent dissection. Discussion: This case shows the importance of early treatment and recognition of rare presentations of ACS such as SCAD. Most cases constitute a conservative approach with medical therapy as over time there appears to be spontaneous healing of the vessel wall, but when the patient is unstable such as in cardiogenic shock, VF, or has ongoing chest pain it warrants a more invasive approach with PCI and medical therapy. This case also shows that there may be an association between SCAD and FMD, such that emerging guidelines recommend after a SCAD event, patients should be screened for FMD with imaging of the renal, cerebrovascular and iliac arteries.