Slide 1: 40-YEAR-OLD FEMALE ℅ ACUTE CHEST PAIN DURING A COURT HEARING. WHAT DOES THE EKG SHOW?

Slide 2: THIS IS A NORMAL EKG! However – TROPONIN-I PEAKED AT 1.4ng/mL.

Slide 3: What next? Active chest pain, trop elevation, normal EKG: posterior lead EKG! V7-V9 with no ischemic changes: left heart catheterization! Though this patient’s TIMI score is 1 (+trop), her story was convincing enough to merit LHC. Note: for more on posterior lead EKGs, see our previous 12-lead Thursday on electrically silent MIs.

Slide 4: What did the cath show? Hint: there’s a lesion on this image – try to spot it!

Slide 5: Can you spot the lesion? Looks like a flap!

Slide 6: This is SCAD! (Spontaneous coronary artery dissection). What: an intimal tear or a hematoma in the false lumen of the artery causes coronary obstruction and ACS. Who: think: young woman, current/recent pregnancy, connective tissue disease, stressful situation

Slide 7: Diagnosis made! Now what? Management of SCAD: 1. Medical management via beta blockers and BP control (> PCI) 2. No clear evidence for antiplatelet therapy 3. Retrospective studies show statins may be associated with worse outcomes (increased recurrence) – though reasonable to use statins in known CAD or dyslipidemias. Further workup: consider screening for connective tissue disease to detect high-risk vascular abnormalities.

References

  • Nishiguchi et al. Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome. Eur Heart Journal: Acute Cardiovasc Care. 2016. PMID 24585938.
  • Tweet MS et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection.Circulation. 2012 Jul 31;126(5):579-88. PMID 22800851 .
  • Hayes SN et al. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018 May 8;137(19):e523-e557. PMID 29472380.