Abstract 15587: Combined Spontaneous Coronary Artery Dissection and Takotsubo Cardiomyopathy in a Patient With Chest Pain

Abstract

Introduction: Spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TCM) are uncommon non-atherosclerotic causes of acute myocardial infarction (MI). These patients have fewer cardiovascular risk factors than those who have atherosclerotic MI. Clinical presentation in both subsets of MI is identical due to which diagnosis requires echocardiography and coronary angiography. The incidence of TCM and SCAD in the same patient is scarce and only documented in a few case reports and a case series. Case presentation: We present the case of a 50-year-old female with a past medical history of hypertension, hypothyroidism, and median arcuate ligament syndrome. She presented to the emergency department with intermittent chest pain radiating to her upper back, both arms, and her left jaw and it was associated with nausea. On examination, she was tachycardic, tachypneic, and anxious. She had normal heart sounds with no chest tenderness. Her EKG demonstrated ST-elevations in leads II, III, aVF, V4, V5, and V6. Laboratory results showed elevated high sensitivity troponin of 11,949 (pg/ml) and 30,256 (pg/ml) four hours later. The patient underwent emergent coronary angiography, which revealed diffuse tubular stenosis suggestive of type 2 SCAD in the second obtuse marginal artery but otherwise normal coronary anatomy with minimal stenosis. Left ventriculogram showed antero-apical, apical, and infero-apical hypokinesis and basal hyperkinesis, suggestive of Takotsubo cardiomyopathy. Transthoracic echocardiogram (TTE) completed 48 hours later demonstrated improved contractility with lateral wall hypokinesis. The patient was managed conservatively with medical management, and she was discharged on aspirin, plavix, carvedilol, isosorbide mononitrate, and losartan. Conclusions: SCAD and TCM are uncommon diagnoses that can rarely co-exist. TTE can help diagnose TCM in patients with chest pain and elevated cardiac biomarkers. Non-occlusive coronary vasculature is a diagnostic criterion per the proposed Mayo Clinic criteria. This case highlights the importance of coronary angiography in patients with TCM for assessment of potential co-existent coronary vascular pathology; SCAD in our case.