Recurrent spontaneous coronary artery dissection, diagnostic issues and management: a case report

Background Spontaneous coronary artery dissection (SCAD) is a severe and under-diagnosed pathology that generates diagnostic and therapeutic difficulties. Case summary This case is about a 45-year-old female with a history of coronary spasm in 2012 without ergonovine provocation confirmation. She was admitted in 2014 for an acute coronary syndrome (ACS) revealing an aspect of thrombus of the left anterior descending (LAD) coronary artery. GPIIb/IIIa antagonists, unfractionated heparin and antiplatelet therapy were introduced. Angiographic control ten days later showed that the lesion was not thrombotic but a SCAD which spread on left main coronary artery and LAD proximal part. Angiographic control at one month showed a partial healing but persistent focal dissection of mid LAD treated by 2 bioresorbable vascular scaffolds. In 2018, she presented with a new case of SCAD treated at another hospital, where she had been misdiagnosed with myocarditis. A review of the angiograms revealed findings typical of distal SCAD of the circumflex artery. In June 2022, new ACS was related to a right coronary artery (RCA) SCAD. The distal part was occluded by an extensive hematoma. This was turned into a dissection by using cutting balloon. No stent was implanted. Discussion SCAD is a complex condition that presents diagnostic challenges, as this case illustrates. Such diagnostic errors can lead to the prescription of inappropriate medication, such as anticoagulant therapy, which may exacerbate the condition by increasing the size of the haematoma. It is also a condition that can recur, and clinicians must bear this in mind.