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Abstract

A 23 year old man presented with anterior ST elevation myocardial infarction while playing football and gave a 3 week history of recreational intravenous steroid abuse. Coronary angiogram showed a large persistent filling defect in left main stem extending into LAD and intermediate arteries. This was felt to be either spontaneous left main dissection precipitated by heavy exertion or left main stem thrombosis facilitated by intravenous steroid abuse over the previous 3 weeks. He was offered immediate surgical revascularisation but elected instead to have delayed surgery after 2 weeks unless symptoms worsened. Repeat coronary angiogram, two weeks later, however, showed considerable improvement with only a small amount of residual thrombus in left anterior descending artery and hence it was elected to continue with medical treatment. Following further 6 weeks, repeat coronary angiogram showed total resolution with normal coronary artery appearances. At 7 year follow up, patient is free of all cardiac symptoms and is leading a normal life.We discuss the diagnostic dilemma in this 21 year old man with no risk factors for coronary artery disease, who had features that pointed towards both spontaneous coronary artery dissection (SCAD) and steroid facilitated thrombosis and in whom intravascular ultrasound underlined at least the facilitative role of atheromatous left main plaque. We also discuss the etiopathogenesis, presentation and the various treatment options of the rare spontaneous left main dissection and the steroid induced even rarer left main thrombosis and the quasi-facilitative role of at least mild atherosclerosis in this patient, and the relative rarity of spontaneous resolution with conservative management.