Spontaneous multi-vessel dissection associated with mid-menstrual cycle estrogen surge presenting as an acute myocardial infarction: A caution to be vigilant

We are reporting the case of a middle aged female who presented with an acute anterior wall myocardial infarction on the thirteenth day of menstrual cycle (the timing of peak estrogen surge during a menstrual cycle of average duration). The patient was thrombolysed initially. Subsequent to the initial resolution of the symptoms immediately after lysis, the patient developed recurrence of symptoms and ECG showed the occurrence of re-infarction. The angiogram revealed a spontaneous multi-vessel dissection involving left main, left anterior descending (LAD) artery and left circumflex artery extending from the left main downwards without any obvious predisposition. The arteries were laden with thrombus and percutaneous intervention was initially impossible. The patient was given an infusion of abciximab following the thrombus burden reduced enabling an intervention. The patient underwent successful stenting from LMCA to LAD and has been asymptomatic and has maintained stent patency at 3 months of follow up. The correlation of spontaneous coronary artery dissection with mid-menstrual estrogen surge has never been discussed previously and is an important consideration in management of young females who present with idiopathic coronary syndrome and illustrates the role of diagnostic angiogram before the administration of thrombolytic therapy in such cases.