SPONTANEOUS CORONARY ARTERY DISSECTION PRESENTING WITH STEMI AND CARDIOGENIC SHOCK

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare phenomenon, diagnosed in 0.1% of all patients who undergo coronary angiography with a mean age at presentation of 35-40 years [1, 2]. Several predispositions have been associated with SCAD, including female sex, atherosclerotic disease, recent pregnancy, and connective tissue disorders [3]. CASE PRESENTATION: A 35-year-old nulliparous female with polycystic ovarian disease alone presented with complaints of sudden-onset substernal “chest burning”. She presented two days prior to an outside facility with similar chest pain and was found to have an elevated troponin to 0.34 ng/dL, a small pericardial effusion on transthoracic echo (TTE), and a negative PE-CT. The diagnosis was viral myopericarditis. Upon arrival to our ED, her EKG revealed ST-segment elevation in V2-V4 and troponin levels were >100,000 ng/L. She was taken emergently for cardiac catheterization and underwent Impella placement for stabilization of cardiogenic shock. Left heart catheterization (LHC) demonstrated a SCAD of the left main (LM) coronary artery with extension into the left anterior descending (LAD) and left circumflex artery (LCX) with TIMI 0 flow into the LAD. She underwent PCI to the ostial LM, ostial to distal LAD, and proximal LCX with restoration of flow down the LAD, covering the flap of the LM dissection. After reperfusion, TTE revealed an ejection fraction (EF) of 25-30% with severe hypokinesis of the entire anteroseptal, periapical, and inferoseptal walls. Her stay was complicated by brief ventricular fibrillation. Her cardiac output normalized, her Impella was removed, and by hospital day 10 her LVEF improved to 40-45%. Additional workup included unremarkable carotid and renal dopplers, ANA, and ANCA. She was discharged home with a wearable defibrillator. DISCUSSION: Presentations of SCAD vary depending on severity and can include acute coronary syndrome, heart failure, or sudden cardiac death [4]. SCAD is typically diagnosed with coronary angiography, most commonly manifesting as the diffuse smooth stenosis pattern. Treatment depends on severity, and large or multivessel involvement requires revascularization [1, 5, 6]. Our case, a young patient without typical risk factors for cardiac disease, highlights the morbidity associated with SCAD and the importance of early diagnosis. Therefore, it is reasonable to look for evidence of vasculopathy, including fibromuscular dysplasia, and dissection in other vascular beds. While recognized hereditary connective tissue disorders are rare, an association with a defect in PHACTR1/EDN1 genetic locus has been noted [7]. Morbidity from SCAD is high, and in addition to high rates of major adverse cardiac events, recurrence is reported to be ∼10% at 3 years [6]. CONCLUSIONS: Our case demonstrates the importance of considering alternative diagnoses of chest pain in young females without typical cardiac risk factors. Reference #1: 1. Maeder, M., et al., Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Cardiol, 2005. 101(3): p. 363-9. Reference #2: 2. DeMaio, S.J., Jr., S.H. Kinsella, and M.E. Silverman, Clinical course and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol, 1989. 64(8): p. 471-4. Reference #3: 3. Biswas, M., A. Sethi, and S.J. Voyce, Spontaneous coronary artery dissection: case report and review of literature. Heart Views, 2012. 13(4): p. 149-54. 4. Sabatine, M.S., et al., Case records of the Massachusetts General Hospital. Case 28-2010. A 32-year-old woman, 3 weeks post partum, with substernal chest pain. N Engl J Med, 2010. 363(12): p. 1164-73. 5. Auer, J., et al., Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound. Heart (British Cardiac Society), 2004. 90(7): p. e39-e39. 6. Hayes, S.N., et al., Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation, 2018. 137(19): p. e523-e557. 7. Adlam, D., et al., Association of the PHACTR1/EDN1 Genetic Locus With Spontaneous Coronary Artery Dissection. J Am Coll Cardiol, 2019. 73(1): p. 58-66. DISCLOSURES: No relevant relationships by Waleed Al-Darzi, source=Web Response No relevant relationships by Hussayn Alrayes, source=Web Response Speaker/Speaker's Bureau relationship with Abbott Please note: $1001 - $5000 Added 03/14/2019 by Jennifer Cowger, source=Web Response, value=Honoraria Advisory Committee Member relationship with Medtronic Please note: $1001 - $5000 Added 03/14/2019 by Jennifer Cowger, source=Web Response, value=Consulting fee Scientific Medical Advisor relationship with Procyrion Please note: $1-$1000 Added 03/14/2019 by Jennifer Cowger, source=Web Response, value=Travel Speaker/Speaker's Bureau relationship with Medtronic Please note: $1001 - $5000 Added 03/14/2019 by Jennifer Cowger, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Abbott Please note: $1-$1000 Added 03/14/2019 by Jennifer Cowger, source=Web Response, value=Travel Speaker/Speaker's Bureau relationship with Medtronic Please note: $1-$1000 Added 03/14/2019 by Jennifer Cowger, source=Web Response, value=Travel No relevant relationships by Alexander Michaels, source=Web Response