Background: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (MI) and sudden cardiac death (SCD). SCAD is mostly described in young females with a sparse cardiac history. The pathophysiology of SCAD has not been clearly elucidated in the literature and the underlying etiology continues to be investigated. Case presentation:We describe a unique case of a 57-year-old female who presented with chest pain who was found to have a ST segment elevation myocardial infarction (STEMI) on electrocardiogram. Cardiac coronary angiography demonstrated SCAD of the mid to distal left anterior descending (LAD) artery who was originally treated with, but ultimately failed, medical management. Less than 24 hours after presentation, she had a ventricular fibrillation cardiac arrest with repeat coronary angiography indicating complete occlusion of her mid to distal LAD, resulting in management with coronary artery bypass grafting (CABG). Conclusion:Conservative management of SCAD should be attempted with patients however LAD lesions are at high risk for cardiac decompensation, requiring invasive revascularization with PCI or CABG.