At The Heart of the Matter: An Atypical Case of Spontaneous Coronary Artery Dissection

Abstract

CASE: A 51-year-old female with a history of hypertension and ADHD presented to the emergency department with sharp substernal pain and nausea. Initial EKG showed anterior ST-segment elevation. Patient vitals were 53 bpm, 170/110 mmHg, and 90% O2 saturation on room air. The patient was on a prescribed amphetamine for ADHD and propanol. She was given nitroglycerin by EMS; and carvedilol, heparin, and ticagrelor at the hospital. Echocardiogram found diffusely hypokinetic to akinetic apex, distal anteroseptal wall, and mid to distal anterior/anterolateral walls, suggestive of ischemia or stress-induced cardiomyopathy. Subsequent coronary angiography demonstrated 95% stenosis in the left anterior descending artery with ulceration, type 4 dissection segment, and thrombosis. Two drug-eluting stents were placed successfully; lisinopril and carvedilol were increased, and atorvastatin and ticagrelor were initiated. CONCLUSION: This patient presented with multiple risks for SCAD: female, hypertension, use of dextroamphetamine-amphetamine, family cardiac history, and middle-age. However, the consult differential did not include SCAD. Instead, the leading diagnosis was stress-induced cardiomyopathy due to EKG presentation. SCAD was discovered after initial stent placement. SCAD is a rare vascular emergency where a tear spontaneously forms in a coronary artery and can precipitate myocardial infarction by occluding perfusion, potentially resulting in sudden death. Confounding factors in the presentation were newly increased dextroamphetamine-amphetamine and alcohol use, indicating that typical SCAD presentations, as taught, may not be inclusive of all cases. CLINICAL SIGNIFICANCE: Broadening differentials or diagnostic criteria for SCAD could improve SCAD screening and diagnosis. Additionally, providers have been shown in the literature to underdiagnose cardiac events and undertreat pain in females relative to male patients experiencing the same events. This case exemplifies the importance of a more inclusive differential to provide comprehensive care for female patients.