B50-13 Spontaneous Coronary Artery Dissection Recurrence in a Middle-aged Woman: A Case of Medically Managed Distal RCA Dissection

Introduction Spontaneous coronary artery dissection (SCAD) is an uncommon, non-atherosclerotic cause of acute coronary syndrome (ACS) that predominantly affects women without traditional cardiovascular risk factors. It is often associated with pregnancy, hormonal therapy, or connective tissue disorders. Recurrence, particularly among patients with psychiatric comorbidities or stimulant use, remains underrecognized. We present a case of recurrent SCAD involving the distal right coronary artery (RCA) in a middle-aged woman successfully managed with medical therapy. Case Description A 38-year-old woman with a history of SCAD-related NSTEMI, hypertension, hyperlipidemia, ADHD, anxiety, PTSD, and prior in-vitro fertilization presented with acute retrosternal chest pain radiating to her back and arms. On admission, she was hemodynamically stable (BP 134/92 mmHg). High-sensitivity troponin increased from 15 ng/L to 52,018 ng/L; ECG showed no ST-T abnormalities. Overnight, she developed recurrent chest pain requiring morphine and lorazepam. The next morning, she experienced bradycardia (HR 30s) and hypotension (SBP 60s) with recurrent pain, prompting urgent evaluation. Coronary angiography revealed a long, smooth distal RCA stenosis consistent with SCAD. Left ventricular ejection fraction was 55-60% with preserved wall motion. She was managed conservatively with aspirin, atorvastatin, metoprolol, nifedipine, and isosorbide mononitrate. Vyvanse and prazosin were discontinued. She remained stable and was discharged with plans for outpatient coronary CTA to evaluate for fibromuscular dysplasia (FMD). At three-month follow-up, she remained asymptomatic without recurrence. Notably, she had a prior SCAD episode in 2024 involving a 99% stenosis of the first diagonal branch (D1) with preserved TIMI-3 flow, treated conservatively. Discussion SCAD accounts for up to 4% of ACS cases and disproportionately affects young to middle-aged women. Recurrence occurs in approximately 10-20% of patients. Psychiatric comorbidities and stimulant medications may increase arterial shear stress and precipitate recurrence. In hemodynamically stable patients with preserved flow, conservative management is preferred, as per 2023 AHA/ACC recommendations, since percutaneous intervention can extend dissection or intramural hematoma. Impact Statement This case highlights the importance of early recognition and individualized management of recurrent SCAD. Awareness of psychosocial and pharmacologic contributors is essential to optimize outcomes and prevent recurrence. Learning Objectives 1. Recognize SCAD as a cause of ACS in women without traditional risk factors. 2. Understand the rationale for conservative therapy in stable SCAD cases. 3. Identify psychiatric comorbidities and stimulant use as potential recurrence risks. 4. Emphasize long-term surveillance and multidisciplinary care to prevent recurrence.