Multimodality Imaging Approach to Treatment in Spontaneous Coronary Artery Dissection (SCAD)

Background: Spontaneous coronary artery dissection (SCAD) is the spontaneous separation of the layers of the epicardial coronary artery wall by intramural hemorrhage that is not associated with atherosclerosis, iatrogenic injury, or trauma. The gold standard for diagnosis is coronary angiography however often times requires multi-modality imaging approach with cardiac computed tomography angiography (CCTA). Often times ultimate therapy involves conservative management pending stability of patient. In this case report we discuss how a multi-modality imaging approach can assist in both diagnosis, treatment, and monitoring of SCAD.

Case Presentation: A 32 year old female with a past medical history of tobacco abuse who originally presented as an inpatient for class II chest pain with associated recent intense workouts. Patient was found to have a NSTEMI with a troponin that peaked at 4.68.

Given patients age and overall lack of significant risk factors patient underwent further stratification with a CCTA which demonstrated severe anatomical stenosis of the proximal left anterior descending (LAD) artery 70-99%. Given these findings patient subsequently underwent left heart catheterization. Upon coronary angiogram patient was found to have an intimal flap which extended from the proximal LAD into the left main (LM) artery. As the patients chest pain had resolved at the time of the heart catheterization, lack of dynamic EKG changes, and overall hemodynamic stability patient was treated conservatively with medical therapy. Patient subsequently underwent repeat coronary angiogram 72 hours later which showed consistent findings confirming diagnosis of SCAD. Patient was initiated on dual antiplatelet therapy and statin and discharged in stable condition. Roughly a month post discharge patient underwent repeat CCTA which revealed significant improvement in previously appreciated intimal flap.

Discussion: This case report demonstrates a presentation of SCAD with commonly associated demographics of a young otherwise healthy female. SCAD is commonly associated with intense emotional stress or physical exertion. SCAD is often associated with non-coronary arteriopathies including fibromuscular dysplasia and cerebral aneurysm. There are three major types of SCAD in which our patient demonstrated type I which is defined by contrast staining of the arterial wall with a radiolucent flap present. Our case demonstrated a good utilization of a multi-modality imaging approach with both coronary angiogram and CCTA. CCTA has emerged as an appropriate non-invasive imaging choice for many diagnosis, including SCAD. This patient displayed a good outcome with initial diagnosis via coronary angiogram and continued non-invasive monitoring in the outpatient setting with CCTA. Ultimately, the appropriate management plan is debated however given the overall stability of the patient percutaneous coronary intervention of these lesions can be extremely challenging and lead to worse outcomes. Thus, appropriate treatment has shifted to conservative therapy with 30 days of dual antiplatelet therapy and avoidance of strenuous activities.