Spontanous coronary artery dissection: A case report

Spontaneous Coronary Artery Dissection (SCAD) is a rare aetiology of acute coronary syndrome (ACS), characterised by intramural haematoma formation in coronary arteries unrelated to atherosclerosis or trauma. It is often overlooked in young women with ACS symptoms, leading to adverse outcomes. Timely diagnosis and management are crucial. This case report details a middle-aged female with SCAD presenting with chest pain. A 40-year-old woman presented with worsening retrosternal chest pain over 2 months, associated with elevated stress levels. Her medical history includes untreated hypercholesterolaemia (cholesterol 6.8 mmol/L, triglycerides 3.48 mmol/L, LDL-c 6.0 mmol/L), non-fatty alcoholic liver disease, and smoking. Initial ECG findings showed T-wave inversion, saddle ST segments, and elevated troponin levels. Echocardiography displayed moderate left ventricular dysfunction, with lateral, inferior, and posterior wall motion abnormalities. The working diagnosis was ACS. Thorough clinical examination and investigations ruled out differentials including pneumonia, pulmonary embolism, aortic dissection, myocarditis and Takotsubo's cardiomyopathy. Coronary angiography revealed left main stem/left anterior descending artery stenosis with SCAD, confirmed by subsequent CT coronary angiography. Conservative management was employed, and follow-up cardiac MRI at 6 months post-SCAD was reassuring, showing preserved myocardial thickness and LAD territory scarring with no significant ischaemic changes. SCAD, though rare, may be underdiagnosed due to diagnostic challenges.1 It mimics ACS secondary to coronary artery disease and its reliance on coronary angiography causes delayed diagnosis in non-PCI centres.2 Conservative management is recommended for uncomplicated cases, supported by cardiac rehabilitation and moderate exercise.3 Post-SCAD chest pain is common.4 Research from Canada and the United Kingdom have also led to the establishment of specialised SCAD clinics to manage this rare condition.5 Hypertension increases the risk of recurrent SCAD; therefore good blood pressure management is vital.6 Imaging is recommended to identify extra-coronary high-risk aneurysms or dissections linked to underlying arteriopathies.7 For example, SCAD often coexists with Fibromuscular Dysplasia (FMD), an arteriopathy affecting medium-sized arteries leading to stenosis and aneurysm formation.8 Typically patients are females aged between 20 and 60 years. The cause of FMD is unknown, and diagnosis is made by angiography. Despite initial reports, less than 5% of SCAD cases are related to pregnancy.9 Hormonal changes with high progesterone levels can result in weakening of the vessel wall. Increased cardiac output and circulatory volume, along with the acute haemodynamic stress of childbirth can lead to pregnancy-related SCAD.10