A case of a chest pain zebra

16 Jun

Case: A 32 yo female 2 weeks post-partum who presents with sudden onset dull left anterior chest pressure and mild shortness of breath. No trauma or other sx. No PMH or significant FH.

 

Other than HR 105, vitals are normal including bilateral BP’s.  Her exam is unremarkable.

 

Your Ddx is broad- you consider pericarditis, myocarditis, PE, cardiomyopathy, aortic dissection, ACS, gastritis, esophageal disruption, pneumothorax, pneumonia, substance use…

Her CXR is normal.

EKG is below:

ekg-sca

Her Tn returns at 4.58 and her other labs are unremarkable (including a negative d-dimer). Cardiology admits her, brings her to the cath lab and she is found to have a…

 

 

 

Spontaneous coronary artery dissection

This is very rare- about 300 documented cases according to 1 journal article in 2008, 70-90% reported cases are in women

Risk factors: Female, pregnancy or post-partum, fibromuscular dysplasia, extreme exercise, connective tissue disorder, cocaine use, marked HTN

Sx/presentation: Chest pain, diaphoresis, palpitations, shortness of breath- symptoms of ACS. Patients may present with an NSTEMI, STEMI, CHF, unstable angina, or even a pericarditis clinical syndrome.  Traditionally, patients will have ST elevation in the leads corresponding to the dissecting artery, but this is not always the case.

Dx: Many options for diagnostic studies: cardiac cath, coronary angiogram, intravascular US, optical coherence tomography, CTA

Tx: Given the low incidence, there is a significant amount of variability. Main options include medical management, coronary bypass, and stenting.

Bottom line: SCA is a very rare diagnosis with a high mortality. Consider in the ddx, particularly in young female patients with chest pain and an ACS picture. Classically, you will see ST elevations and an elevated troponin. For me the take away is keeping a high index of suspicion in patients with concerning histories or exams.

 

Submitted by Heather Groth.

 

References:

Cleveland Clinic http://my.clevelandclinic.org/services/heart/disorders/spontaneous-coronary-artery-dissection

Tweet, et al. Clinical Features, Management, and Prognosis of Spontaneous Coronary Artery Dissection. Circulation. 2012;126:667-670.

Vanzetto, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European Journal of Cardio-thoracic Surgery. 2008: 35 (3), 205-254. 

Zampieri et al. Follow up after spontaneous coronary artery dissection: a report of five case series; Heart.1996: 75, 206-209.

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