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Case 9-1: Spontaneous coronary artery dissection in a young, postpartum female

Patient Presentation

A 27-year-old woman presented with severe, substernal chest pain 2 weeks after a normal spontaneous vaginal delivery.

Figure 9-1.

12-lead electrocardiogram. RA = ST segment elevations in the anterior precordial leads

Clinical Features

This patient had stable vital signs and was in moderate painful distress with no abnormal physical findings.

Differential Dx

  • Aortic dissection

  • Pericardial tamponade

  • Pericarditis

  • Acute myocardial infarction

  • Myocarditis

  • Postpartum cardiomyopathy

  • Pulmonary embolism

Emergency Care

An EKG was remarkable for ST-segment elevations in the anterior precordial leads. Bedside emergency department (ED) cardiac ultrasound demonstrated an apical and septal wall motion abnormality. The patient was treated with nitroglycerin, aspirin, heparin, and ticagrelor and went to the cardiac catheterization lab.

Outcome

Cardiac catheterization revealed a 100% occlusion of the proximal left anterior descending coronary artery from a spontaneous coronary artery dissection, with initial thrombolysis in myocardial infarction (TIMI) flow = 0. Two drug-eluding stents were placed, and her EKG returned to normal. Shortly after returning to the coronary care unit, the patient suffered a ventricular fibrillation cardiac arrest and was successfully resuscitated with one defibrillation. Repeat cardiac catheterization revealed patent stents, and the arrest was thought secondary to a reperfusion arrhythmia. The patient went on to have an uncomplicated hospital course and was discharged neurologically intact.

Key Learning Points

  • The classic patient profile for spontaneous coronary artery dissection is young, female, and postpartum.

  • The left anterior descending artery is most commonly involved.

  • Spontaneous coronary artery dissection has been increasingly discovered in women, accounting for 24% of myocardial infarctions in women under the age of 50 years.

  • Treatment can be complex and depends on the presence or absence of acute myocardial infarction.

Further Reading

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Alfonso  F, Bastante  T, García-Guimaraes  M,  et al. Spontaneous coronary artery dissection: new insights into diagnosis and treatment. Coron Art Dis. 2016;27(8):696–706.
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Cade  JR, Szarf  G, de Siqueira  ME,  et al. Pregnancy-associated spontaneous coronary artery dissection: insights from a case series of 13 patients. Eur Heart J Cardiovasc Imaging. 2017;18(1):54–61.  [PubMed: 26928981]
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Faden  MS, Bottega  N, Benjamin  A, Brown  RN. A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium. Heart. 2016;102(24):1974–1979.  [PubMed: 27411842]
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Saw  J, Aymong  E, Mancini  GB, Sedlak  T, Starovoytov  A, Ricci  D. Nonatherosclerotic coronary artery disease in young women. Can J Cardiol. 2014;30(7):814–819.  [PubMed: 24726091]
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Zingarelli  A. Spontaneous coronary dissection: Unravelling the complex riddle of conservative or interventional treatment. Int J Cardiol. 2017;229:124.  [PubMed: 28029413]

Case 9-2: Incorrect computer ...

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