243 Spontaneous Coronary Artery Dissection in the Emergency Department: The Elusive Dissection

Abstract

Emergency physicians are well versed in the dangers of arterial dissection; however, there is one type of dissection that has proven to be particularly elusive. Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women. In a population that is otherwise considered low risk there is a danger of missed diagnosis. In this study we describe associated symptoms and initial diagnostic findings among those who have presented with SCAD. We aim to increase awareness of this potentially fatal diagnosis among emergency practitioners. Subjects were those who had consented to the Mayo Clinic “Virtual” Multicenter SCAD Registry with a SCAD diagnosis as confirmed by angiography. Data were collected from both medical records and surveys following the SCAD event. Data points regarding symptoms were abstracted from survey narrative responses. Exact words were extracted when possible; however, synonyms were also used to help classify (for example, “an elephant on my chest” was categorized as “pressure/weight on chest”). Of the 1196 subjects included, 95.6% were female and mean age was 46±9 years. Chest pain was reported during the initial SCAD event in 95.7% (3.8% report no chest pain, and 0.5% did not respond). The most common descriptors of chest symptoms were pain (as the only descriptor), pressure/weight on chest, and tightness with radiation most often mentioned in one or both arms or shoulders (85.1%, left more often than right). After chest symptoms, the next most frequently reported were nausea (18.9%), shortness of breath (17.8%), and diaphoresis (17.2%). Presentation included unstable angina (1.7%), non ST-elevation myocardial infarction (57.5%), ST-elevation myocardial infarction (38.5%), and cardiac arrest (8.8%), with some patients included in multiple categories in the setting of evolving changes. Most common electrocardiogram (ECG) findings reported were ST elevation (45.8%), T-wave abnormality (21.8%), and normal ECG (15.8%). Initial troponin values were negative in 20.1% of patients. There was no ECG or troponin data available in 9.8% and 14.5%, respectively. Our study, developed from the largest SCAD database to date, provides insight into how SCAD presents to the emergency department. With young healthy women often considered “low risk” for ACS and common risk calculators heavily relying on atherosclerotic risk factors, it is important to define this presentation and bring awareness to emergency physicians. The data shown here emphasizes the importance of including SCAD on the chest pain differential, as well as obtaining appropriate diagnostic workup including serial ECG and troponin levels in young women who present with chest pain.