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We performed a PubMed literature search using the search terms exercise, sports, spontaneous coronary dissection, and athletics. We found seven cases of spontaneous coronary artery dissection that had occurred during intense physical exercise. Vigorous exercise can provoke acute ischemic events, but such events occur primarily in adults with atherosclerotic disease. Many of the cases reported as spontaneous coronary artery dissection are more likely atherosclerotic plaque rupture, in which cases they are not truly spontaneous. Because spontaneous coronary dissection is so rare, there are no available recommendations on how to manage young athletes with this condition. We permitted this athlete to return to limited competition, without data to support either a total restriction or even a limited restriction, with the written understanding that a recurrent event is possible but probably unlikely. In summary, spontaneous coronary artery dissection should be considered in young individuals presenting with exercise-related acute ischemic cardiac events.

A 25-year-old woman who was at 24 weeks' gestation presented to our institution with a 2-day history of worsening epigastric and midthoracic back pain. The patient denied chest pain, shortness of breath, palpitations, nausea, and vomiting. Her medical history was significant for a history of 2 spontaneous abortions, hypertension, and anemia. Her only medications were prenatal vitamins and iron supplements. On physical examination, blood pressure (BP) of 120 ⁄ 70 mm Hg was noted in the right arm and 152 ⁄ 90 mm Hg in the left arm. Neck examination revealed 1+ bilateral carotid pulsations with loud carotid and subclavicular bruits. There was no jugular venous distension or thyromegaly. Normal first and second heart sounds were normal intensity with II ⁄ VI diastolic murmur at the left upper sternal border. Abdominal examination revealed positive bowel sounds, tender epigastrium with no fundal tenderness, rebound, or guarding. Lower extremities revealed 2+ pitting edema. Right upper extremity (radial and brachial) pulses were absent with 1+ left brachial and radial pulses. Initial laboratory values included mild anemia with hemoglobin of 11 g ⁄ dL. White blood cell and platelet counts, chemistries, liver function tests, urine toxicology, and pancreatic enzymes were within normal limits. Urinalysis revealing a 4+ proteinuria. Erythrocyte sedimentation rate was 41 mm ⁄ hr and C-reactive protein was 4.4, respectively. Electrocardiography results showed normal sinus rhythm at 84 beats per minute with no ST ⁄ Twave changes. Chest x-ray showed a mildly ectatic thoracic aorta. Fetal heart tracing at baseline was 140 to 150 seconds with minimal heart rate variability.The patient was admitted to the obstetrics ward for preeclampsia and fetal monitoring. Considering the vascular and cardiac examination findings, the cardiology service was consulted. Transthoracic echocardiography was performed and revealed normal left and right systolic function with mild to moderate aortic insufficiency. No valvular or congenital abnormalities were identified. A computed tomography (CT) scan of the chest without contrast revealed circumferential wall thickening of the descending aorta with no dissection. Limited magnetic resonance imaging (MRI) of the abdomen without gadolinium showed irregular wall thickening of the aorta and significant stenoses of the proximal celiac and superior mesenteric arteries. Based on American Society of Rheumatology classification criteria, the patient was diagnosed with Takayasu arteritis and started on intravenous steroids. She later underwent duplex ultrasonography of the neck, which showed absence of flow in the innominate, common carotid, and right vertebral artery. Flow was maintained in the internal carotid artery through retrograde flow in the external carotid artery. The right subclavian artery was occluded with minimal flow in the right axillary artery through collaterals, which was later confirmed by selective angiography after pregnancy.The following morning, the patient complained of recurrent epiga...