Author + information
- Giuliana Capretti1,
- Luca Ferri1,
- Massimo Slavich1,
- Manuela Giglio1,
- Luciano Candilio2,
- Alberto Margonato1,
- Antonio Colombo3 and
- Alaide Chieffo1
Patient initials or identifier number
Relevant clinical history and physical exam
A 49-year-old woman with no significant cardiovascular risk factors was admitted to the emergency department with typical angina and sweating prior to a yoga class and following a particularly stressful period involving divorce and redundancy.
Relevant test results prior to catheterization
ECG showed anterolateral ST-segment elevation, bedside echocardiogram revealed mild left ventricular systolic dysfunction with apical akinesia. Serum troponin-T concentration was elevated. The patient was loaded on aspirin and clopidogrel and taken for emergency cardiac catheterization.
Relevant catheterization findings
Coronary angiogram via right radial access (6F) showed non-obstructive disease in right coronary and circumflex arteries and segmental luminal narrowing in small distal left arterial descending (LAD) artery. This was not thought to be due to significant stenosis [Thrombolysis In Myocardial Infarction (TIMI)-3]. There was no clear angiographic evidence of coronary dissection or spasm. Left ventriculogram confirmed apical akinesia.
Given clinical history and presentation, chest pain (CP) resolution and hemodynamic stability, Takotsubo cardiomyopathy was suspected and therefore a conservative approach was adopted. Cardiac Magnetic Resonance Imaging was not undertaken due patient’s claustrophobia. Subsequent cardiac Computed Tomography (CT) showed mild-moderate distal LAD stenosis, however, it was not possible to differentiate whether this was secondary to atherosclerotic plaque disease or intramural hematoma. The patient was discharged on medical therapy. Repeat cardiac CT a month later showed no further evidence of LAD stenosis and hematoma resolution, therefore suggesting a diagnosis of spontaneous coronary artery dissection (SCAD).
The differential diagnosis of acute presentations with CP and ST-segment elevation on ECG can be very broad and potentially lead to patient mismanagement. Non-angiographically evident SCAD should be suspected particularly in middle-aged women with no significant cardiovascular risk factors when coronary angiography shows no obvious intimal flap with evidence of arterial lumen diameter reduction. In such cases, further evaluation with cardiac CT may help elucidate the underlying physiopathological process avoiding the risks of potential complications of intracoronary imaging in the setting of coronary dissection.