Interventional Dilemma in a Young Woman With Spontaneous Coronary Artery Dissection Who Presented With High-Risk Non-ST-Elevation Myocardial Infarction (NSTEMI) Progressing to ST-Elevation Myocardial Infarction (STEMI)

Abstract

Spontaneous coronary artery dissection (SCAD) is an infrequent presentation of acute myocardial infarction in young women and denotes the non-atherosclerotic separation of the coronary artery wall. Precipitating causes include fibromuscular dysplasia, postpartum hormonal changes, multiparity, connective tissue diseases like Marfan syndrome, autoimmune conditions, and hormonal therapy. It is often underdiagnosed due to a low index of suspicion based on age and gender bias as well as knowledge about different angiographic variants in SCAD. Intracoronary imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is used for patients where coronary angiography fails to secure a diagnosis to increase the diagnostic yield. The mainstay of stable SCAD is conservative management. However, there are no definitive guidelines due to limited clinical experience. Treatment involving percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), fibrinolytic therapy, and mechanical hemodynamic support should be individualized depending upon clinical presentation, type, and extent of dissection, hemodynamic instability, critical anatomy involvement, and the extent of ischemic myocardium. We are presenting a case of a young female who presented with non-ST-elevation myocardial infarction (NSTEMI) that progressed to ST-elevation myocardial infarction (STEMI). A coronary angiogram showed a tortuous left anterior descending artery (LAD) with a distal 100% occlusion due to SCAD. PCI was attempted but the guidewire could not be navigated intraluminally past the occlusion. CABG was not pursued due to the distal location of the occlusion and lack of visualization of the distal vessel. Our case provides a useful learning opportunity for physicians who may come across similar clinical presentations. In patients with high-risk features of SCAD who are deemed inoperable, timely and appropriate medical management may be a useful alternative for PCI/CABG and the recurrence rates of SCAD are very low.