Spontaneous Coronary Artery Dissection-A Diagnosis To Be Considered in Young Patients (Full title below)

Spontaneous Coronary Artery Dissection — A Diagnosis To Be Considered in Young Patients Presenting with Acute Myocardial Infarction

From the ‡Emergency Department, Hospital de Messejana, Fortaleza, Brazil, *Haemodynamics, Hospital Mont Klinikum, Fortaleza, Brazil, †Haemodynamics, Hospital de Messejana, Fortaleza, Brazil. The authors report no conflicts of interest regarding the content herein. Manuscript submitted April 1, 2009, provisional acceptance given April 27, 2009, final version accepted May 4, 2009. Address for correspondence: Rafael N. Macedo, Emergency, Hospital de Messejana, Rua Marcos Macedo, 1390, ap 201, Fortaleza, CE, Brazil – 60150-190. E-mail: rafaelnmacedo@yahoo.com.br

_______________________________________________ ABSTRACT: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and sudden death. Various therapeutics strategies have been proposed, from conservative management to surgical or percutaneous revascularization. Standard therapy has not been yet established. We report a case of a 34-year-old athlete, presenting chest pain after intense physical activity. Once the clinical and laboratory findings were typical of an acute coronary syndrome, the patient underwent cardiac catheterization, which showed right coronary artery dissection. Initially, conservative management was established, but, after seventy-two hours of no pain relief, a percutaneous stent implantation procedure was implemented resulting in a complete angiographic and clinical response. This case and review of literature emphasize that although SCAD is a very rare entity, it must be kept in mind in the differential diagnosis of acute, sharp chest pain in young physically active individuals, with no apparent risk factor for coronary artery disease.

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J INVASIVE CARDIOL 2009;21:E245–E247 Key words: acute coronary syndrome, SCAD Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and sudden death. Approximately 300 cases have been reported in the literature1 and despite that, its diagnosis remains delayed or missed. Although the specific etiology of this condition is still uncertain, it is known that more than 70% of the reported cases occurred in women1 with nearly two-thirds of SCAD cases occur during childbirth without any history of atherosclerotic disease.2 Some other suspected risk factors are: preexisting coronary artery disease, cystic medial degeneration, use of oral contraceptives or illicit drug use, and practice of heavy exercise.3 Standard therapy has not been yet established since the limited evidence regarding treatment is based on clinical case description and retrospective analysis. Various therapeutic strategies have been proposed, from conservative management4 to surgical or percutaneous revascularization.5 Case report. A 34-year-old male professional soccer player, presented to a community hospital with vague chest pain after 3 hours of intense physical activity. Once he had no risk factors or family history of coronary disease, the patient received symptomatic medication and discharged home. On the following day, he presented with a new episode of chest pain, but this time with typical symptoms of acute coronary disease, being transferred to a coronary disease specialty center. At presentation, his blood pressure was 120 x 80 mmHg and pulse was 60 beats/minute. The clinical examination was unremarkable. Electrocardiography showed a regular sinus rhythm, with negative T waves in leads DII, DIII and aVF, and ST-elevation from V2 to V5. Laboratory exams revealed creatine kinase (CK) level of 1577 (normal

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