Let's welcome Dr. Shafer back to the blog. Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you. Some really interesting learning points on this one. Here is a link to the original post in case you missed it, and here is the answer...
Diagnosis: Spontaneous LAD dissection
This is an unusual diagnosis that is mainly described as case reports in the literature. In 1996 only 100 cases in the world had been identified (2). Of these reported cases, 75% were diagnosed at autopsy and the rest were diagnosed with coronary angiography (1). The majority of these cases (approximately 75%) were in women, and of these cases, 32% of the patients were pregnant, post-partum, or taking oral contraceptives (2). One study in 2009 observed that one out of ten women under the age of 50 who clinically presented with ACS instead had a coronary dissection on coronary angiography (3).
LAD dissection is considered especially disastrous and results in malignant arrhythmias, severe CHF, extensive infarct and sudden death (2). The clinical presentation of coronary dissection is similar to that of a patient having an acute MI, but they are usually younger and without the cardiac risk factors. It is important to note that spontaneous coronary dissection can be recurrent. The etiology of this disease is unclear, but some autopsies have demonstrated an eosinophilic penetration of the tunica adventitia and it is postulated that this subsequently causes damage to the collagen, elastin and smooth muscle wall (2). Treatment options for these patients include medical management only versus stenting versus bypass surgery. There is no treatment standard at this time and the prognosis of these patients who survive is unknown. However, the case reports overall seem to demonstrate that at least one year post-event survival rate is quite high.
For our case presentation, the patient was emergently taken to the cath lab where her diagnosis of spontaneous LAD dissection was made. She was stented at this time and started on Aspirin, Metoprolol, and Effient. She had a complicated hospital course, developing pericarditis, a small pericardial effusion, and a new apical thrombus. Ultimately, however, after a week her symptoms had dramatically improved and she was discharged home.
Spontaneous coronary dissection is a rare but rapidly fatal diagnosis that should be considered in the differential diagnosis of young patients who present with symptoms of ACS; it can be both diagnosed and treated in the cath lab. Remember that diffuse ST segment elevation in the younger patient with chest pain will not always equate to a diagnosis of pericarditis.
- Spontaneous Coronary Artery Dissection, Aneurysms, and Pseudoaneurysms: A Review. Echocardiography. 2004: 21(2), 175-182.
- Zampieri et al. Follow up after spontaneous coronary artery dissection: a report of five case series; Heart.1996: 75, 206-209.
- Vanzetto, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European Journal of Cardio-thoracic Surgery. 2008: 35 (3), 205-254.