Fibromuscular Dysplasia with Spontaneous Coronary Artery Disease Presenting as Acute Myocardial Infarction

Abstract

A 40-year-old female presented to a rural hospital with crushing substernal chest pain. An initial electrocardiogram showed ST elevation in lead II and aVF with elevated troponin I. She was immediately transferred to a tertiary care hospital. An emergent coronary angiogram did not show any significant coronary artery disease. On the second day, the patient experienced recurrence of severe chest pain with ST elevations in leads I, aVL, V5-V6, ST depressions in V1-V3, T-wave inversion over V2-V5. The troponin I level increased to > 40 ng/ml (normal 0.0 to 0.04 ng/ml). An emergent angiogram was performed revealing local dissection of the mid to distal left main coronary artery and a totally occluded diagonal artery. It was deemed unsafe to perform percutaneous coronary intervention because it was a non-flow limiting left main coronary artery dissection and was difficult to cannulate with the guide catheter. Subsequently, an elective angiogram was performed after a 48-hour interval to evaluate the progression of dissection and to make a definitive decision for revascularization versus medical management. On the third angiogram, stenosis seen in the diagonal branch on the previous angiogram progressed to dissection, and local dissection of the left main coronary artery seen on the previous angiogram spontaneously resolved. The patient was symptom-free and hemodynamically stable. It was decided to manage the patient conservatively due to the spontaneous resolution of occlusion in the diagonal artery and dissection of the left main coronary artery. The patient was started on conservative medical treatment. A magnetic resonance angiography of the right internal carotid artery revealed a “string of beads” appearance, which confirmed the diagnosis of fibromuscular dysplasia. She was followed closely in the clinic and has remained asymptomatic for the past one year.

Spontaneous Coronary Artery Dissection in the Setting of COVID-19 Pandemic-Related Stressors: A Case Report

“…The association between FMD and SCAD is well established, but SCAD is believed to be an uncommon initial presentation of FMD [ 6 ]. Therefore, recognition of risk factors, symptoms and findings is crucial to timely diagnosis and appropriate treatment of SCAD.…”

Spontaneous Coronary Artery Dissection in a Female Patient With Acute Myocardial Infarction

“…Empiric dual antiplatelet therapy benefits by preventing prothrombotic changes and should be started immediately once the diagnosis is confirmed [ 12 ]. Beta-blockers help by lowering blood pressure and heart rate and thus reducing shear force on the arterial wall, which prevents the extension of distension [ 13 ]. The role of statins is uncertain as there are limited studies of their use in SCAD.…”

“…Thrombolytic agents are avoided in the management of SCAD because of the risk of extension of dissection and intramural hematoma [ 13 ]. A retrospective study shows that 60% of patients with SCAD who received thrombolytic agents required either rescue percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) [ 14 ].…”

Approach to Imaging of Patients Presenting With Acute Coronary Syndrome With No Culprit Lesion Identified at Angiography

“…18 SCAD is a subpopulation of MINOCA caused by a separation of the layers of the epicardial coronary artery with intramural hematoma, with or without an intimal tear, and is also strongly associated with fibromuscular dysplasia. 19 Patients with SCAD often present with a wide range of symptoms, the most common of which is chest discomfort. 20 Other symptoms of SCAD include neck pain, arm pain, back pain, diaphoresis, dyspnea, nausea or vomiting, dizziness, and fatigue.…”

“…Although SCAD accounts for <1% of all total MIs, it disproportionately accounts for 25% to 33% of MI in women under 50, with a higher prevalence during pregnancy and postpartum 18 . SCAD is a subpopulation of MINOCA caused by a separation of the layers of the epicardial coronary artery with intramural hematoma, with or without an intimal tear, and is also strongly associated with fibromuscular dysplasia 19 . Patients with SCAD often present with a wide range of symptoms, the most common of which is chest discomfort 20 .…”