Abstract 12259: Recurrent Coronary Artery Dissection in Patient With Systemic Medium-Sized Vessel Vasculitis

Abstract

Introduction: Universal definition of myocardial infarction (MI) categorizes spontaneous coronary artery dissection (SCAD) as Type 2 ischemia from non-atherothrombotic obstruction. SCAD is rare but growing evidence suggests it is more common than previously understood. Overlap in clinical presentation with Type 1 MI makes invasive coronary angiography (ICA) the gold standard for diagnosis. Here we present a patient with polyarteritis nodosa (PAN) and the sequelae of coronary artery aneurysms and dissections visualized by ICA and further characterized by noninvasive coronary computed tomography angiography (CCTA). Case Report: A 37-year-old man with smoking and hypertension history presented with acute chest pain that felt similar to when he was diagnosed with SCAD of the first diagonal branch one year prior by ICA. Workup then included elevated inflammatory markers and further imaging demonstrating ectatic and beaded-appearing major intra-abdominal and vertebral arteries consistent with PAN. He completed outpatient cyclophosphamide and continued on chronic oral steroids.The catheterization lab was activated on this presentation for ST segment elevations on initial ECG concerning for an inferior MI. Here the distal branches of the right coronary artery (RCA) had new aneurysms and long stenoses with severe luminal narrowing and intramural hematoma consistent with Type 2 SCAD. The culprit lesions had normal TIMI grade 3 flow so were not revascularized. CCTA further characterized the filling defect and RCA false lumen as Type 1 SCAD. Echocardiogram demonstrated a new wall motion dysfunction in correlative distribution. He was optimized on medical therapy including continued dual antiplatelet agents and steroids. Discussion: This patient’s case lends itself to the hypothesis that his PAN manifested ectatic changes to the coronary vasculature from inflammation that predisposed him to recurrent dissection. Therefore, it is reasonable to initiate a vasculitis workup following discovery of coronary artery ectasia and/or dissection. CCTA may even be an effective tool for diagnosis and surveillance of such disease in the right patient and as a means to avoid invasive testing risks.