P137 STEMI IN YOUNG MAN: A "CHALLENGE" CASE OF SPONTANEOUS CORONARY DISSECTION

Abstract

Abstract A 21–years old male patient presented to the emergency department complaining chest pain in the night. There was no family history of cardiovascular events; he did not have any known risk factors and denied drug abuse. Pathological history was positive for allergic asthma. On admission, he was paucisyntomatic. The physical examination was normal. Blood pressure was slightly elevated. The EKG showed sinus rhythm, ST segment elevation in high lateral leads and reciprocal ST depression in inferior leads. The echocardiogram showed anterolateral and mid–apical septal akinesia of the left ventricle with ejection fraction of 45%. The urgent coronary angiography showed suspected coronary artery dissection of the first diagonal branch with TIMI flow grade 2 and myocardial brigde of the middle segment of the left anterior descending artery (fig.1). An initial conservative management with beta–blockers, dual antiplatelet therapy, statin and ACE–inhibitors was adopted: the patient was asymptomatic and the EKG became normal during the coronary angiography. In addition the young age, the suspicion of Spontaneous Coronary Artery Dissection (SCAD) and TIMI flow grade 2 in the culpit vessel provided support of conservative treatment. The hospital stay was unremarkable. Troponin T peak value was 1542 pg/ml (n.v. < 13 pg/ml). Thrombophilia screening showed mild hyperhomocysteinemia and homozygous MTHFR mutation. Autoimmunity screening was negative. The subsequent echocardiogram showed mid–distal hypokinesia of the anterolateral, inferolateral and anterior wall of the left ventricle with normal ejection fraction. The CT angiography of the cerebral and abdominal vessels was normal. The cardiac magnetic resonance imaging (MRI) confirmed a recent acute myocardial infarction of the mid–apical portions of the anterior and anterolateral wall and normal global contractile function of the left ventricle (fig. 2, 3). At 30 days follow up, the echocardiogram remained unchanged; the coronary AngioCT scan confirmed the dissection of the ostium and proximal section of the first diagonal branch; the cardiac MRI showed transmural fibrosis of the anterolateral wall with normal left ventricular ejection fraction. SCAD is an under–reported pathology. It can lead to acute coronary syndromes and life–threatening consequences. Diagnosis and treatment are still under debate. The presented clinical case, effectively treated with conservative therapy, represented a "challenge" in the acute phase.