Syncope: Chief complaint for spontaneous coronary artery dissection without other signs of acute coronary syndrome

Abhijai Singh,Christopher Robert Chew

doi:10.5348/100096z06cc2021cr

Abstract

Introduction: Spontaneous coronary artery dissection is an exceptionally rare cause of acute coronary syndrome (ACS) with a reported incidence of 1–4% of all ACS cases. It is most prevalent in young women with the left anterior descending artery and left main are the most common arteries involved. Case Report: The patient is a 75-year-old man with a prior medical history of hypertension, gastroesophageal reflux disease (GERD), and pulmonary fibrosis presented to the emergency department (ED) with syncope. The patient reported a burning sensation over the central chest different from his GERD. On physical exam, the patient had a 3/6 holosystolic murmur throughout the left pericardium. His laboratory workup was benign with negative troponins and normal electrocardiogram (EKG). Chest X-ray during this time revealed no acute processes and computed tomography angiography (CTA) of the chest was positive for a 4.1 mm fusiform ascending aortic aneurysm. 2D Echo revealed new cardiomyopathy with ejection fraction (EF) of 35–40% with trivial mitral regurgitation (MR) and mild aortic regurgitation. Left heart catheterization revealed left main stenosis of 75%, left anterior descending (LAD) with ostial stenosis of 80% and 30% stenosis of the left circumflex and right coronary artery (RCA). The LAD had a proximal eccentric plaque which under intravascular ultrasound (IVUS) revealed a dissection. The patient underwent a coronary artery bypass grafting (CABG) and did well until discharge home. His postoperative course was complicated by new onset of atrial fibrillation/flutter. The patient was discharged to rehab with Eliquis, baby aspirin, Coreg, and Digoxin. Conclusion: Our case is unique in view of the unconventional age group, gender, and odd symptomatology. We hope to increase the awareness among medical practitioners for this high morbidity diagnosis if not identified correctly.

Highlights

Spontaneous coronary artery dissection is an exceptionally rare cause of acute coronary syndrome (ACS) with a reported incidence of 1–4% of all ACS cases
The patient is a 75-year-old man who presented to the emergency department after having two syncopal episodes over a week’s time which both occurred while the patient was walking
Chest X-ray during this time revealed no acute processes and computed tomography angiography (CTA) of the chest was positive for a 4.1 mm fusiform ascending aortic aneurysm that is unassociated with the left anterior descending (LAD) dissection

Summary

INTRODUCTION

Spontaneous coronary artery dissection (SCAD) is a rare cause of ischemic heart disease that is poorly understood. The patient is a 75-year-old man who presented to the emergency department after having two syncopal episodes over a week’s time which both occurred while the patient was walking During both instances, the patient lost consciousness but neither time was chest pain reported. Cardiology determined a diagnostic heart catheterization was warranted to determine if the cause of the low ejection fraction was due to ischemic versus non-ischemic causes as the patient had no history of congestive heart failure and normal echoes in the past. The left main coronary artery had 30–40% ostial disease and a plaque with a cross sectional area of 5.1 mm creating a stenosis of 75%. The left circumflex coronary artery and right coronary artery had about 30% stenosis At this time cardiothoracic surgery was consulted and recommended a CABG be performed because of the patient’s critical multi-vessel disease and dissection.

DISCUSSION

Findings

CONCLUSION