SPONTANEOUS LEFT MAIN CORONARY ARTERY DISSECTION: WHAT IS THE TREATMENT OF CHOICE?

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare and underdiagnosed entity, that is more prevalent in middle-aged women. The dissection of the coronary artery represents a tear of the coronary arterial wall with the creation of a false lumen. SCAD can impede the blood flow to the myocardium, resulting in myocardial ischemia. SCAD can present with unstable angina, acute myocardial infarction, ventricular arrhythmia and occasionally sudden cardiac death. There is no consensus on the treatment, however evolving data suggests invasive revascularization therapy in patients with left main SCAD. CASE PRESENTATION: A 48 year old female, with a medical history of migraine headache presented to the emergency department (ED) with acute, severe (10/10), non-exertional, substernal chest pain radiating to the back, associated with nausea and shortness of breath that started an hour prior to presentation. In the ED, her vital signs remained stable and first troponin was noted at 0.02 ng/ml which peaked at 35.7 ng/ml in 6 hours. Her EKG showed ST segment elevation in the anterior leads and depression in the reciprocal leads. Aspirin 325 mg and Ticagrelor 180 mg were given on presentation. However, patient was noted to have sudden onset loss of consciousness and was found to be pulseless on exam. The cardiac monitor revealed ventricular fibrillation. Resuscitation was performed, followed by defibrillator shock (200 J). ROSC was obtained and the patient was intubated for airway protection. She was emergently taken for cardiac catheterization. Findings revealed left main and LAD ostial SCAD with thrombus into the mid vessel. It showed left ventricular ejection fraction (EF) of 30% with LVEDP of 32 mm Hg. Percutaneous transluminal coronary angioplasty (PTCA) of the ostial and proximal LAD was performed. She was monitored in the Intensive care unit thereafter. The rest of her hospital course was uneventful. She was given Aspirin 81 mg daily, Ticagrelor 90mg twice daily, and Metoprolol Succinate 25 mg daily. At two weeks follow up, she did not report any anginal symptoms. Echocardiography showed an ejection fraction (EF) of 50-55% with normal ventricular volume, wall thickness and systolic function. At four months follow up, echocardiography showed an EF of 65%. DISCUSSION: A conservative approach with medical management (anti-platelet, Beta-blockers) with close hemodynamic monitoring are preferred and recommended treatment for SCAD. However, in case of recurrent angina or hemodynamic collapse, revascularization therapies including PTCA should be considered. This case highlights the importance of timely diagnosis and PTCA in SCAD with a good prognosis. CONCLUSIONS: More light must be shed on SCAD evaluation and treatment. As the presentation may be quite similar to acute coronary syndrome, PTCA remains the standard of care followed by medical management with beta-blockers and anti-platelet therapy REFERENCE #1: Saw J., Aymong E., Sedlak T., et al. (2014) Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes. Circ Cardiovasc Interv 7:645–655. REFERENCE #2: Lettieri C., Zavalloni D., Rossini R., et al. (2015) Management and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol 116:66–73.CrossRefPubMedGoogle Scholar6. Tweet M.S., Hayes S.N., Pitta S.R., et al. (2012) Clinical features, management and prognosis of spontaneous coronary artery dissection. Circulation 126:579–588 REFERENCE #3: Tweet M.S., Eleid M.F., Best P.J., et al. (2014) Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circ Cardiovasc Interv 7:777–786.Abstract/FREE Full TextGoogle Scholar DISCLOSURES: No relevant relationships by Dana Ahmad, source=Web Response No relevant relationships by Peter Farrugia, source=Web Response No relevant relationships by HARESH GANDHI, source=Web Response No relevant relationships by Mohamad Hamad, source=Web Response No relevant relationships by Mohsin Mughal, source=Web Response No relevant relationships by Shailee Patel, source=Web Response